transforming maternity services together · appendix 3.1: bsw lms “better births” gap analysis...

Bath & North East Somerset, Swindon & Wiltshire Local Maternity System

Transforming Maternity Services Together

Pre Consultation Business Case

Version 6 Final

12 November 2018

Appendices

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Contents Chapter 3: Drivers for change ................................................................................. 4

Appendix 3.1: BSW LMS “Better Births” Gap Analysis ........................................... 4

Appendix 3.2: RightCare Data ............................................................................... 7

Appendix 3.3 BSW LMS engagement activities .................................................... 10

Chapter 4: Clinical Case for Change – additional data ................................... 29

Appendix 4.1: Caesarean birth rates .................................................................... 29

Appendix 4.2: Women with complex pregnancies ................................................ 29

Appendix 4.3: Age at booking ............................................................................... 30

Appendix 4.4: Induction of labour (IOL) ................................................................ 30

Appendix 4.5: Infant mortality and stillbirth ........................................................... 31

Chapter 5: Developing Our Proposals .................................................................. 32

Appendix 5.1: Development of the long list ........................................................... 32

Appendix 5.2: Long list of maternity service options ............................................. 34

Appendix 5.3: Maternity services options - advantages and disadvantages ..... 36

Appendix 5.4: Stakeholder group initial likes and dislikes of the long list .............. 55

Appendix 5.5: Membership of non-financial appraisal group ................................ 58

Appendix 5.6: Raw and weighted scores for long list of options ......................... 59

Appendix 5.7: Assumptions for high level staffing and financial models for short listed options .................................................................................................... 61

Appendix 5.8: Integrated Impact Assessment ...................................................... 68

Appendix 5.9: Bath University report of the analysis of the geographic allocation of maternity services ............................................................................................... 107

Appendix 5.10: Bath University report of the analysis of maternity services in the RUH catchment area .......................................................................................... 136

Chapter 6 – Our proposed changes .................................................................... 197

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Appendix 6.1: Vision for BSW LMS Offer to Women .......................................... 197

Appendix 6.2 Letter from B&NES CCG re future of Paulton Hospital ............... 202

Chapter 7: Governance ........................................................................................ 203

Appendix 7.1: terms of reference of the Acute Maternity Services Redesign Steering Group ................................................................................................... 203

Appendix 7.2: Project Management Roles ....................................................... 207

Appendix 7.3: Letter from B&NES CCG confirming it will discharge its legal responsibility for the service reconfiguration to Wiltshire CCG ........................... 209

Appendix 7.4: Updates provided to CCG Governing Body meetings (private sessions) ............................................................................................................ 210

Appendix 7.5: Letters of support from CCGs and STP Board ............................. 212

Appendix 7.6: Letter from Somerset CCG confirming support ............................ 213

Appendix 7.7: Engagement with scrutiny bodies ................................................ 214

Appendix 7.8: Letters of support from HOSCs/Health & Wellbeing Boards ........ 217

Appendix 7.9: South West Clinical Senate Panel report ..................................... 222

Chapter 8: Consultation Plans ........................................................................... 222

Appendix 8.1: Transforming Maternity Services ................................................. 223

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Chapter 3: Drivers for change

Appendix 3.1: BSW LMS “Better Births” Gap Analysis

All maternity providers in England were required to complete a self-assessment against the “Better Births” recommendations in 2016, for each of the seven themes.

Each provider within the BSW LMS measured themselves against the seven themes to produce a GAP analysis, identifying the where services were delivering on the themes, and the challenges that needed to be addressed, identifying the priority through a RAG (red/amber/green) rating of each theme.

These self-assessments were reviewed at the BSW Maternity Strategic Liaison Committee (MSLC) and common themes drawn together to help shape the priorities of the NSW Maternity Transformation Plan.

Work stream Positives Challenges Overall RAG rating

Responsible committee for addressing challenges

Work stream

Positives Challenges Overall RAG rating

Responsibility for addressing challenges

Personalised care and choice

All 3 providers currently looking at ways of giving unbiased information

• 2 providers have 3 out of 4 birth place choices.

• Personalised plans not fully implemented.

Red

Reconfiguration proposed changes

Continuity of

In some areas there is evidence of continuity of in the antenatal period

• All providers have a high number of midwives that have chosen to work part time.

• None of the three maternity services have

Red

Maternity Transformation Plan

Key:

Red – unlikely to achieve this recommendation without significant investment or service transformation, which has not yet been agreed.

Amber – have a good possibility of achieving this recommendation within the national time-frame.

Green – already meet this recommendation or can realistically achieve it by March 2017.

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Work stream



Carer

continuity within the maternity workforces.

Better Postnatal and perinatal mental healthcare

Perinatal infant mental health pathway is being developed across the LMS footprint and all providers are engaged with this development

• Post-natal care provision is patchy and there is little consistency in the post-natal offer.

• There is a variation in availability of community mental health services.

Amber


Working across boundaries

All providers are involved with local systems- MSLC and planned maternity forum

• There are no shared policies and pathways between the providers.

• Digital systems are not compatible between providers.

• Community hubs are not yet a consideration.

Amber


Safer care

All providers site a culture of learning and continuous improvement

Duty of Candour in place in all organisations

The rapid redress scheme is an expectation but this has not been outlined nationally

Green


and

Reconfiguration

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Work stream



All providers are signed up to the National Maternity and Neonatal Health safety Collaborative

proposed changes

Multi-professional working

All providers have teams that train and learn together

• Peer reviews not yet in place

• No systems in place to learn across the region

Amber


Payment System

National system not yet in test

Red


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Appendix 3.2: RightCare Data

RightCare data packs from each of the three BSW LMS CCGs have been reviewed by the LMS to identify any opportunities. The RightCare data was sourced from the Better Births report and the wide confidence intervals have been noted. The current packs, which have not been updated as part of the national RightCare data refresh, have focused on prevention and public health. The maternity packs include benchmarked data for under-fives – these elements have not been linked to this maternity work stream. The reports are from 2015/16 data and there have been actions undertaken to reduce the identified variance.

The chart below shows benchmarked results for Wiltshire CCG. This indicates opportunities around smoking cessation and neonatal and infant mortality rates. Since publication Wiltshire CCG has pump primed providers for early implementation of the national Stillbirth care bundle, which has reduced rates. Smoking cessation continues to be an active action through our midwifery and public health teams.

Figure 1: RightCare data for maternity pathway 2015/16, Wiltshire CCG

The information below features Swindon CCG data. This indicates opportunities around low birth rate and smoking cessation. Both areas are activity being reviewed. The under-18 conception rate has decreased since the publication of this data.

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Figure 2: RightCare data for maternity pathway 2015/16, Swindon CCG

The chart below features B&NES CCG data. This indicates a potential opportunity around low birthweight babies, which is being picked up via the BSW LMS Safety Subgroup.

Figure 3: RightCare data for maternity pathway 2015/16, B&NES CCG

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We have reviewed the following RightCare indicators for Wiltshire CCG that have undergone a refresh since May 2016:

• Spend on Conditions of Neonates per 1,000 ASTRO-PU weighted population • Spend on Maternity and Reproductive Health per 1,000 ASTRO-PU weighted

population • Neonatal - Elective spend on discharges per 1,000 age-sex weighted

population • Neonatal - Non-elective spend on discharges per 1,000 age-sex weighted

population • Neonatal - Rate of bed days per 100,000 age-sex weighted population • Neonatal - Total spend on discharges per 1,000 age-sex weighted population

There are no further opportunities shown for the BSW LMS

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Appendix 3.3 BSW LMS engagement activities

This chapter details the process undertaken and the feedback received from those that were engaged. Also included is the relevant feedback from other engagement work and feedback received by the RUH.

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MSLC “Place of Birth” survey questionnaire

MSLC “Place of Birth” survey questionnaire

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Informal Engagement on RUH maternity services

The RUH informal engagement process ran over a 12 week period in January to March 2017.

At the start of the process we wanted to understand what matters most to our service users so that we understand what families want from our maternity services and what drives the choices they are making in relation to their care and decision making around where to have their baby. We wanted to find out what families feel is good about our current service provision and what they would like to see improved. We also wanted to understand from our staff what was good and not so good about the service.

The objectives we were seeking through the informal engagement include:

• To understand what matters most to the women who use our services. • To share an understanding of the challenges facing the current RUH service

delivery, including but not restricted to financial constraints, environmental circumstances, underutilisation and staffing levels, and to develop ideas together in order to co-create some of the solutions to the challenges outlined.

• To obtain feedback to further understand what determines the choice people make about where to give birth.

• To obtain feedback on the aspects of the current services which service users, staff and other key stakeholders would like to see maintained, e.g. high quality.

• To obtain feedback on any aspects of the services that service users, staff and other key stakeholders would like to see improved.

• To test recommendations outlined in the RUH internal maternity service review undertaken in August 2016.

An initial clinical case for change was written which enabled us to focus on key themes that we wanted to explore with our stakeholders.

We sought views in four ways:

Stakeholder events

We held four informal face to face discussion groups:

Tuesday 14th February 2017 Oasis Boardroom, RUH Bath, Monday 27th February 2017 Victoria Hall, Church Street, Radstock Tuesday 7th March 2017 Assembly Hall, Market Place, Melksham Tuesday 14th March 2017 Wiltshire Council, County Hall, Trowbridge

We invited service users and their families, Healthwatch, GPs and commissioners to attend, advertising widely through social media, flyers in GP practices, child health

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centres. The list of stakeholders receiving invitations to the informal discussion is below:

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At each session, the project team gave a presentation that described the current service and the challenges being faced. These were then discussed in smaller groups to gain feedback.

We also discussed specific issues we also sought feedback and views on a number of areas:

• Development of an Alongside Midwifery Unit (alongside birth centre in the documentation) at the RUH

• Making effective us of the Freestanding Midwifery Units (community birth centres in the documentation) run by the RUH

• Quality of birthing environments • Day assessment unit capacity for close monitoring for mothers and their

unborn baby where complications have developed during pregnancy

All feedback was logged.

Questionnaire

In order to gather a wide range of view from those that were not able to attend a focus group, a questionnaire was developed, and was circulated widely across Wiltshire, Somerset and B&NES. In total 791 people, male and female aged 18 plus, completed the questionnaires.

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The RUH commissioned the Centre for Healthcare Innovation and Improvement at the University of Bath School of Management, to undertake independent analysis of the questionnaire responses, both quantitative and qualitative. The full report can be accessed from the website (www.transformingmaternity.org.uk).

Although not designed to solicit a direct evaluation of the quality of the service experience, the analysis revealed that service users had a generally positive albeit mixed experience of the acute maternity and community services. When asked of what aspects of care service are deemed to be important in general, it emerged that service users wanted to be treated with compassion and within a service that provides personalised care.

Familiarity with the midwife was also seen very important but also knowing that there is specialised care available was also seen as important. Another finding is the importance service users placed on availability of resources in general. Most of the concerns raised in the survey related to the perceived low availability of a range of resources including staff, quality of facilities and parking. Easy access to facilities was also an important concern raised by respondents.

Engaging our stakeholders

The RUH aimed to engage as wide a group of stakeholders as possible during the informal engagement period. A stakeholder map was drawn up which identified the key stakeholders, and they were contacted in the following ways:

• They questionnaire was made available online and in hard copy in clinical areas of the RUH.

• Information was included on RUH and partner websites, including CCGs, with links to the surveys and details of how to get involved. Links to this information were promoted via social media including Twitter and Facebook

• A dedicated email address was established for comment/feedback or send in any questions.

• Information and how to provide feedback was made available in all locations where maternity services are provided.

• Content was supplied to voluntary and third sector publications and websites including National Childbirth Trust (NCT) groups. This included Wiltshire community websites serving all 18 Wiltshire locality ‘wards’ providing people with local interactive notice boards to highlight and discuss local news events and ideas.

• A Communications and Engagement working group was established specifically for scrutiny and development of communications and engagement comprised of communications leads from the Local Health Economy and includes service user representation.

• Face-to-face briefings were held with MPs, county and local councillors. • Updates on engagement activities were provided to B&NES & Wiltshire

scrutiny committees. • HealthWatch scrutiny was achieved through attendance at the informal

engagement events.

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• Media briefings and media releases were provided to local and regional press to promote and public engagement and rationale for change.

Seldom heard groups

A Public and Patient Engagement plan was developed to support the informal engagement activities. The plan described a range of stakeholders, including those with protected characteristics, and those who may be described as ‘seldom heard’ or harder to reach, to ensure they had the opportunity to share their views. See following list.

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Given the diversity of characteristics of those who might be identified as ‘seldom heard’ the Local Health Economy Communications Working Group drew upon the expertise of engagement colleagues, and the experience of previous engagement activity to develop a stakeholder list of individuals and groups who may fall into this category. This included using established resources such as ‘Equality groups in Bath and North East Somerset’ and ‘1Big database’ to identify ‘seldom heard’ stakeholders. As well as identifying stakeholders or individuals representing one or more protected characteristics, the LHE Communications Working Group sought to include those ‘seldom heard’ groups relevant to the BSW LMS, such as traveller and boat dwelling communities, and Polish community groups.

Stakeholders were contacted directly to share their views as part of the informal engagement process to help the RUH understand what matters most to those who use or will use these services - what's good about the options we offer, what could be improved or introduced and what the best mix of choices could look like.

Seldom heard stakeholders/representatives were also asked to spread the word and to help reach as many relevant people as possible, using what they felt to be the most appropriate channels to highlight the opportunities available to share views and provide feedback. Materials such as posters, flyers, online and paper questionnaires and informal discussion sessions were made available, along with the offer to provide any additional information or support that may be required.

Specifically identifying ‘seldom heard’ stakeholders was in addition to the wide ranging activity to raise awareness of informal engagement opportunities amongst those who had used the RUH’s maternity services and individuals or groups who have a special interest in pregnancy, birth and postnatal care.

There was significant coverage in local media, particularly in the Wilshire area, and information was also shared through a broad network of community groups and other channels such as social media, schools, NCT groups and GPs.

Where participants were willing, protected characteristics were captured as part of informal engagement questionnaire.

Staff engagement

Staff engagement was sought prior to the informal engagement process as part of the internal review of RUH-provided maternity services presented to the RUH Management Board in August 2016. This was via a series of focus groups held in all clinical areas of the Maternity services and with the Consultant Obstetric team. The focus groups aimed to find out from staff what they felt was good about our service and areas where they would like to see improvement.

As well as the focus groups, feedback boxes were left in the clinical areas for at least a month in order for staff to reflect on the issues and submit further information if required.

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A follow up staff workshop held on Thursday 6th April 2017, attended by representatives from the community and acute maternity services, to feedback initial themes of what women and their families had being telling us.

Other RUH Engagement

RUH ‘In Your Shoes’ workshops

‘In Your Shoes’ events are planned listening events and are opportunities for staff to listen to women and families sharing their experiences of our care, and to work together to identify what would make the biggest positive difference to their experience and to list the priorities for improvement.

We asked ‘what are your priorities for improvements to our Maternity Services?’ The main themes of feedback were:

• Continuity of Care / Carer through antenatal and postnatal period. • Offer individual, personalised, women-centred care. • Improved communication between staff and with women and their families. • Increased provision for antenatal education to include emotional changes

after birth and how to care for a baby. • Positive staff attitudes. • Facilities to stay after birth at Frome Birthing Centre. • Better facilities available for partners. • Treat women and their families with respect and support choice • Ensure the care offered is consistent between families. • More services offered locally within community to enable greater choice. • Increased staffing levels to ensure high quality care is provided • Offer more support in early pregnancy i.e. drop in appointments or shorter

gaps between appointments. • Offer more Antenatal Education, including the basics of how to care for a

baby. • Ensure a consistent level of care and information are provided to all women.

Choice of birth location

An audit, led by the maternity matron team was undertaken in May 2015, with the aim to understand the reasons why low risk women choose to birth in the Obstetric Unit and understand the factors that influence local women’s choice of birth place. The results are multifactorial, some women chose Bath due to epidural availability, the possibility of transferring in labour was also an influencing factor and there were also external influence such as family preferences, peer, GP and Midwife advice.

Feedback Received To Date

The RUH commissioned researchers from the Centre for Healthcare Innovation and Improvement (CHI2) at the University of Bath School of Management, to carry out a

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quantitative and qualitative analysis of a recent survey of service users on the provision of maternity services in the RUH catchment area.

The following is a summary of the feedback received from the RUH survey. The report is given at Appendix 5.10.

• The respondents of the RUH survey can be summarised as follows: o 86% women o 20% from B&NES, 60% Wiltshire, 17% Somerset o 33% pregnant, or had a baby in the last year o 7% classify themselves as having a disability o The majority (84%) had had an experience of a birth centre

• The highest rated factor when asked what the most important thing to

consider when is choosing where to give birth 95% rated being treated with dignity and respect.

• Having midwife led care, receiving high quality care, being listened to, being able to ask questions and being given easy to understand information were also rated as important.

• Lowest rated factors when asked what is the most important thing to consider when choosing where to give birth was being in a centre where partners can stay overnight 46%.

• 43% identified 6-10 miles as reasonable to travel to a birth centre for giving birth.

• 69% thought there should be a midwife led birth centre at the RUH alongside consultant led care.

• Qualitative analysis found: o Factors affecting a positive experience found

The most frequently mentioned factor in relation to a positive experience was good quality of service with 67% responses;

Availability of good facilities such as rooms, beds, numbers of staff (23% responses) was second;

Location (18%) was the third reason mentioned as important for positive experience;

Continuity of care was important for them (4%). o Factors suggested for improvement

The main suggestion for improvement was the availability and upkeep of facilities with 246 (44.65%) responses;

The second most important suggestion for improvement was improved quality of service, 102 responds (14.9%) defined as more personal care (one-to-one care) as well as more friendly, welcoming and supportive staff;

Improvement of postnatal care with 48 (7.99%) responses, the continuity of care (same midwife) with 16 (2.78%) responses.

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Feedback obtained from focussed engagement on RUH maternity services with hard to reach groups, as outlined earlier, captured over 188 comments from 90 service users, and identified the following themes:

Communication: Many women described how effective communication gave them confidence. This along with getting sufficient and prompt information about their care; strongly influenced how they felt about their experience. It was noted, that this was particularly valued by families who had suffered bereavement and young parents.

Care, kindness and empathy: Families have described how feeling listened to, understood and treated as an individual improved their experiences of care. Many women described when a midwife or other healthcare professional had taken time to understand them, so they did not feel rushed or that they were wasting their time, their experience was better. Women shared numerous experiences of how small perceived acts of kindness, taking time and treating them as an individual really made a difference.

Family focus and environment: Many women positively described the benefits of family involvement in their experience of care. Both women and their partners shared how family involvement, such as partners staying on the ward, had positively contributed to them building relationships with their baby and a positive start to family life. What was highlighted was that although women valued having their partners staying on the ward, they did not feel the facilities or environment were suitable for this. Fathers were also asked to feedback on their experiences via the matron’s questionnaire and this theme was consistent, they valued being able to stay, however due to the environment / lack of facilities often felt in the way.

Patient choice: We asked what influences patient choice and received the following feedback:

a. Access to specialised maternity/obstetric services

In general respondents did not show a strong preference for more specialised maternity care although there is a desire for such care to be easily accessible if and when needed.

Female respondents showed less interest in having access to specialised maternity/obstetric services compared to male respondents while increasing age has a small effect on the desire for having better access to specialised maternity/obstetric services. Familiarity with the service shows reverse association for specialised maternity/obstetric services.

b. Personable midwife led care

Age has a very small (but significant) association with this factor. Disabled respondents were associated with a higher score in this factor. Respondents that were either pregnant or gave birth within the last 12 months were associated with a lower score.

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c. Compassionate and respectful care

No associations were identified between the variables and a desire for compassionate and respectful care. This finding is best interpreted as that all different clusters of service users expect to be cared for with compassion and respect.

Non-RUH feedback

Salisbury Hospital undertook a survey of service users in 2015. This was targeted at a cross section of their community including military personnel and their dependents.

Salisbury and Great Western Hospital undertook Whose Shoes events to receive service user feedback. RUH were involved in the Somerset Whose Shoes event.

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Chapter 4: Clinical Case for Change – additional data

Appendix 4.1: Caesarean birth rates

A total of 2,881 caesarean births took place during 2017/18 of which 1,264 were planned (elective) and 1,617 were unplanned (emergency). The caesarean rates as a percentage of all births for each provider and for the LMS for 2017/18 are shown in the table below.

Table 1: Caesarean birth rates by provider (2017/18)

Hospital Planned Unplanned Total Royal United Hospitals Bath (RUH) 10.6% 15.3% 26.0% Great Western Hospital (GWH) 11.8% 15.1% 26.9% Salisbury Hospital (SFT) 11.8% 11.6% 23.3% LMS Caesarean birth rates 11.3% 14.5% 25.8%

Caesarean births account for just over a quarter of births in the LMS (25.8%). This is compared to the national rate of 12.0% for planned and 15.5% for unplanned caesareans during 2016-171. The national reported rate for total caesarean births was 27.5% in 2016-17 which is slightly higher than for the BSW LMS.

Appendix 4.2: Women with complex pregnancies

Maternity services have seen an increase in the percentage of women with a BMI over 30 at booking in recent years. The table below shows obesity rates for women at time of booking by BMI band, by CCG in 2016/17.

Table 2: Birth rate by age and obesity rate at booking 2016/17

CCG Birth rate from under-18s

conceptions (%)

Birth rate in women aged

40+ (%)

Obesity rate - BMI 40-49.9

(%)

Obesity rate - BMI 50+

(%)

B&NES 0.6 3.5 2.0 0.3 Swindon 1.1 2.0 2.5 0.3 Wiltshire 1.1 3.4 2.8 0.4

In addition, we have seen a number of changes in clinical guidelines, for example, gestational diabetes (GTT testing) and implementation of the still birth bundle, which has increased the number of women requiring obstetric care as part of their maternity pathways and during birth. An example is the increase in the number of

1 NHS Maternity Statistics, England 2016-17, published 9 November 2017 – Method of delivery

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women requiring induction of labour as a result of their higher risk profile and the Small for Gestational Age (SGA) pathway. This is a similar trend to that being seen in other neighbouring trusts as well as nationally.

Appendix 4.3: Age at booking

In recent years we have seen that the percentage of pregnant women under 18 has reduced, while the percentage of women over 40 has increased. The table below gives the birth rates for under-18s and over-40s in 2016/17.

Table 3: RUH birth rate by age at booking 2016/17

CCG Birth rate from under-18s conceptions (%)

Birth rate in women aged 40+ (%)

B&NES 0.6 3.5 Swindon 1.1 2.0 Wiltshire 1.1 3.4

Whilst the numbers are small in comparison to all births coupled with the changes in clinical guidelines for care if women with complex or underlying conditions, we are seeing increased demand for obstetric lead care resulting in capacity constraints for women with higher risk pregnancies.

Appendix 4.4: Induction of labour (IOL)

Induction of labour is generally offered to women with uncomplicated pregnancy between 40 weeks and 7 days and 40 and 12 days to prevent the risks of prolonged pregnancy (NICE 2008), aiming for birth by 42 completed weeks.

Saving Babies’ Lives introduced a care bundle to reduce stillbirth. This bundle brings together four key elements of care that are recognised as evidence-based and/or practice, they are:

• Reducing smoking in pregnancy • Risk assessment and surveillance for fetal growth restriction • Raising awareness of reduced fetal movements • Effective fetal monitoring during labour

Induction of labour rates have increased in all three trusts as a result of this introduction, for Quarter 3 2017/18 the Royal United Hospital had a rate of 28%, Great Western Hospital was 35.2% and Salisbury Foundation Trust was 34.2%. The need for induction of labour under these circumstances outweighs the risks however trusts in the south west recognise that the process for induction differs, as a result the South West Clinical Network is holding a focused workshop in June to examine and scope standardisation of practice.

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Appendix 4.5: Infant mortality and stillbirth

Infant mortality is well recognised as an indicator of population health; the wellbeing of infants, children and pregnant women; and of progress towards addressing inequalities. Most infant deaths occur in the first 27 days of life and stillbirths and infant deaths are associated with a number of complex risk factors, including obesity, smoking, maternal age and inequalities.

It is well recognised that many of the risk factors that impact on low birth weight, infant mortality and stillbirth are disproportionately represented in the most deprived communities, and local data supports this.

The Wiltshire, Swindon and B&NES Stillbirth and Infant Mortality Report (2017) looked in detail at births, stillbirths, perinatal and infant mortality across the LMS and associated risk factors over the last ten years. In summary:

• Infant mortality rates in B&NES and Swindon are reducing while in Wiltshire the trend is relatively flat.

• The stillbirth rates are broadly similar in all areas although the trends vary. There is an upward trend in B&NES, a downward trend in Swindon and a fairly consistent trend in Wiltshire.

• Perinatal mortality rates are similar for all areas. The trend in Swindon is reducing; for B&NES and Wiltshire the trend is flat.

The stillbirth baseline rate is 5.6 per 1000 across the LMS and there are plans, as part of the “Saving Babies Lives Still Birth” care bundle, to reduce rates to 5 per 1000 in 2018/19, 4.8 per 1000 in 2019/20 and 4.6 per 1000 in 2020/21.

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Chapter 5: Developing Our Proposals

Appendix 5.1: Development of the long list

a) Ideas generation for a “great maternity service”

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b) Poster of outputs of service design session

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Appendix 5.2: Long list of maternity service options

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Appendix 5.3: Maternity services options - advantages and disadvantages

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Appendix 5.4: Stakeholder group initial likes and dislikes of the long list

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Appendix 5.5: Membership of non-financial appraisal group

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Appendix 5.6: Raw and weighted scores for long list of options

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Appendix 5.7: Assumptions for high level staffing and financial models for short listed options

a) Staffing model

The RUH clinical team developed the staffing models for each of the 15 options that scored better than the “do nothing” option, using the following assumptions:

Maternity Care Assistants (MCAs) Obstetric Unit stays the same as current 20.5 WTE Alongside Midwifery Unit requires 5.45 WTE Each Freestanding Midwifery Unit requires 5.45 WTE Each traditional midwifery bases for ante/post-natal care requires

1.20 WTE

Midwives Alongside Midwifery Unit requires 10.9 WTE taken out of

Obstetric Unit WTE Current total establishment of 4 community units and Bath Teams

68.14 WTE

To run community units/added to acute split (see table 1)

32.7 WTE

Remaining to be split between traditional midwifery bases for ante/post-natal care (see table 2)

35.44WTE

Dedicated homebirth service to manage caseload and be available for delivery

21.8 WTE

Scenario 13 - no midwifery bases so 35.44 WTE split equally between 3 Community Units

Screening currently excluded

Other workforce No assumed changes to the level of medical staff No assumed changes to the level of A&C staff No assumed changes to the level of Scientific, Therapeutic & Technical staff

No assumed changes to the level of senior managers

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b) Financial model

The RUH financial team costed the staffing models using the following assumptions:

Non pay Assumes Freestanding Midwifery Unit setting at average cost of current 4 sites Assumes Midwife Base at average cost of current 4 Freestanding Midwifery Units Does not include medical and surgical consumables, drugs, gases etc. Does not include modelling for potential changes to travel expenses

Income No assumption for change to CCG Income No assumption for change to Other Income

Financial assumptions

The approach to financial modelling

The financial modelling for both the options appraisal and the final costings of this proposal has concentrated on the costs which are variable in relation to the models of care around midwife and maternity care assistant (MCA) staffing and the location of the birth or ante-/post-natal care. This means that the following have not been included as the assumption is that the costs for these will remain the same regardless of location of birth:

• Medical staff, including consultants and junior doctors. • Administrative staff supporting the service. • Managers supporting the service. • Allied or other health professionals supporting the service. • Medical and surgical consumables, drugs, medical gases etc. • Income received from commissioners. • Income received from other sources.

Cost assumptions

The following assumptions were made in undertaking the financial modelling for the short listed options:

• Pay costs

o Average salaries have been used for staff in post, grouped by each location (i.e. the average salaries for midwives for the RUH site, the community, and the midwife bases). This assumes that the costs related to midwife bases will reflect the core weekday 9am to5pm hours worked, as opposed the acute site which would take account of weekend and unsocial working patterns.

o Average salaries used are for staff currently in post in 2017/18.

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o Nothing has been included to account for the 2018/19 and future pay awards.

• Non-pay

o The non-pay costs look exclusively at the costs for renting and running

the current birth centres and midwife bases. o The midwife bases costs assume that there will be costs for each of the

bases.

Assumptions specific to financial model for options appraisal

The financial model is split into three parts:

• Qualified Midwife staffing • Maternity Care Assistant (MCA) staffing • Estates and premises costs relating to birthing centres in the community and

midwife bases.

The staffing levels for midwives assumes that, with the exception of the models which include a dedicated home birth service, the number of midwives already employed for the births delivered by the Trust for a year is sufficient and is the correct midwife to birth ratio.

The number of MCAs is dependent upon the number of midwives and centres used for births and for ante-/post-natal clinics. Whilst the midwife level is static, the number of MCAs can change depending upon the requirement at each site.

The estates and premises costs use the average values charged in 2017/18 for each unit. The RUH does not own these premises; therefore the costs reflect the rent of the space required and the running of those centres. The charges vary between centres, therefore in order not to prejudge which of the birth centres would be affected by any change; an average cost of the birth centres has been used. This could result in the actual charges being higher or lower than those modelled depending on which configuration of birth centres is chosen.

Premises costs have not been adjusted for inflation or uplift in 2018/19.

The models do not include any element of growth.

The models do not account for any potential changes to travel costs of staff as a result of any changes to the number of birth centres or midwife bases.

The midwife bases are assumed to run on weekdays between 9am and 5pm; whilst the other bases are assumed to be used throughout the day and at weekends.

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Staffing models and costings for short listed options

The overview of the shortlisted options is given below for the do nothing option and those that scored above the ‘do nothing’ option in the non-financial appraisal.

Overview of short listed options

Scenario Option Obstetric Unite

Alongside Midwifery Unit

Dedicated Home Birth Service

Freestanding Midwifery Unit

Traditional Midwifery Bases for ante/post-natal care

16 (do nothing) 1 1 0 0 4 1 1 57 1 1 1 4 4 2 50 1 1 1 2 4 3 54 1 1 1 3 4 4 47 1 1 1 2 3 5 51 1 0 1 2 4 6 44 1 1 1 2 2 7 55 1 0 1 3 4 8 45 1 0 1 2 2 9 52 1 1 0 2 4 10 48 1 0 1 2 3 11 38 1 1 1 1 4 12 58 1 0 1 4 4 13 11 1 1 1 3 0 14 53 1 1 0 3 4 15 56 1 1 0 4 4

Staffing model

There were two criteria for the benefits relating to finances; the first was that the option did not require an increase in staffing. The current staffing model (do nothing option) for midwives and MCAs is 184.2 whole time equivalents (WTE). Only option 52 (scenario 9 below) had fewer staff than the current service (see table below).

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Summary staffing models for short listed options

Scenario Midwife WTE MCA WTE Total WTE Rank by

WTE 16 (do nothing) 139.78 44.42 184.20 2 1 161.58 52.55 214.13 16 2 161.58 41.65 203.23 11 3 161.58 47.10 208.68 14 4 161.58 40.45 202.03 10 5 161.58 36.20 197.78 7 6 161.58 39.25 200.83 9 7 161.58 41.65 203.23 11 8 161.58 33.80 195.38 5 9 139.78 41.65 181.43 1 10 161.58 35.00 196.58 6 11 161.58 36.20 197.78 7 12 161.58 47.10 208.68 14 13 161.58 42.30 203.88 13 14 139.78 47.10 186.88 3 15 139.78 52.55 192.33 4

Costing

The second benefit criterion was that there was no requirement for an increase in funding as the business case is predicated on being cost neutral and effective use of resources.

The outcome of this assessment is set out in the table below:

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Summary of cost appraisal

Scen

ario

Acut

eCo

loca

teHo

me

birt

hsCo

mm

Mid

wife

Ba

sePa

yN

on p

ayTo

tal c

ost

Rank

by

cost

Diff

eren

ce

to cu

rren

t m

odel

Perc

enta

ge

Diff

eren

ce

to cu

rren

t m

odel

161

00

41

£8,1

74,0

20£7

28,4

12£8

,902

,432

3£0

0%1

11

14

4£9

,406

,975

£889

,503

£10,

296,

479

16£1

,394

,047

14%

21

11

24

£9,0

81,8

64£5

67,0

48£9

,648

,911

11£7

46,4

808%

31

11

34

£9,2

44,4

20£5

67,0

48£9

,811

,467

13£9

09,0

359%

41

11

23

£9,0

81,8

16£5

05,9

00£9

,587

,716

10£6

85,2

847%

51

01

24

£8,9

39,2

16£5

67,0

48£9

,506

,264

9£6

03,8

326%

61

11

22

£9,0

54,2

17£4

44,7

52£9

,498

,969

8£5

96,5

376%

71

01

34

£9,0

98,2

87£7

28,2

76£9

,826

,563

14£9

24,1

319%

81

01

22

£8,9

11,5

70£4

44,7

52£9

,356

,321

6£4

53,8

905%

91

10

24

£7,9

91,1

86£5

67,0

48£8

,558

,233

1-£

344,

199

-4%

101

01

23

£8,9

39,1

69£5

05,9

00£9

,445

,069

7£5

42,6

376%

111

11

14

£8,9

22,7

93£3

44,6

72£9

,267

,465

5£3

65,0

334%

121

01

44

£9,2

57,3

58£8

89,5

03£1

0,14

6,86

215

£1,2

44,4

3012

%13

11

13

0£9

,224

,293

£483

,684

£9,7

07,9

7712

£805

,545

8%14

11

03

4£8

,153

,741

£728

,276

£8,8

82,0

172

-£20

,415

0%15

11

04

4£8

,316

,297

£889

,503

£9,2

05,8

014

£303

,369

3%

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Only two of the scenarios achieved any potential efficiencies which could be reinvested into service improvement, and of these scenario 9 was again the most cost beneficial proposal, where significant reinvestment in the estate and birthing environment is made possible.

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Appendix 5.8: Integrated Impact Assessment

BANES, Swindon and Wiltshire Local Maternity System

Integrated Impact Assessment

Version number and revisions record

Version Date Originator Approver Description

1 24/7/18 Sarah MacLennan 1st draft

2 13/09/18 Sarah MacLennan 2nd draft

(update military families’ engagement)

3 10/10/18 Sarah MacLennan 3rd draft

(update of TIA v2)

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Executive Summary

Good maternal health and high quality maternity care has a significant and on-going effect on the health and wellbeing of mothers and their newborn babies. A child’s start in life continues to impact on the healthy development of children and on their resilience later in life. The National Service Framework (NSF) for Children, Young People and Maternity Service (2004) sets out the need for flexible services with a focus on the needs of the individual, particularly those who are vulnerable (DoH, 2004).

All services across the Bath & North East Somerset, Swindon and Wiltshire Local Maternity System (BSW LMS) strive to provide local, safe high quality services to meet the needs of the people using them. The staff providing the services are proud of the focus on woman and family centred care, giving them choice a proactive approach to feedback in order to continually improve the service.

With continual improvement in mind, a detailed assessment of the current maternity services across the Bath and North East Somerset, Swindon and Wiltshire (BSW) geography was undertaken began in 2016. Our assessment also took into consideration the recommendations highlighted in the Better Births Review and The Birthplace in England Research Programme (2011).

As part of our LMS response to the national Better Birth recommendations, we have co-created a Maternity Transformation Plan with women, families, staff and partners.

This co-creation included workshops, face to face interviews, feedback questionnaires, drop in sessions and structured meetings.

The feedback we received provided a number of opportunities for improvement including:

• Improved patient experiences and outcomes • Care provided closer to home • To ensure that the majority of people have the same options within our

maternity system, no matter where they live • Reducing inequality an improving access to health services • Better, more efficient use of NHS resources • More efficient and improved use of our staff and our buildings

Services provided across the local maternity system vary in terms of what is available to women and their families and this case for change aims to address these disparities.

The need for these improvements provides the drivers and a rationale for a review across our local maternity system. Services need to ensure there is:

• Parity of access with equality of service provision • Continuity of care and carer

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The paper concludes with a number of recommendations for service reconfiguration

This Integrated Impact Assessment (IIA) details the engagement we have undertaken so far to ensure that as wide as possible an audience has been offered the opportunity to provide feedback.

The IIA is iterative, however, and we expect updated versions to be provided throughout the journey of the pre-consultation process and the actual public consultation itself, as we become aware of groups, communities or individuals who have not been consulted but who want to have their say. Version control will be detailed on the front cover of the document.

The IIA includes:

1. Quality Impact Assessment 2. Equality Impact Assessment 3. Travel Impact Assessment

Summary of proposed changes

In conclusion of the review work undertaken, a proposal has been developed for public consultation, of which there are four elements. These are:

• Reducing the number of freestanding, midwife-led community maternity units which support birth from four to two

• The creation of Alongside Midwifery Units at the Royal United Hospital, Bath and at Salisbury Foundation Trust

• The future use of nine community post-natal beds • At a later date, develop Community Hubs for additional post and ante natal

community support

A further detail of the preferred proposal can be found on page 53 of the Pre-Consultation Business Case.

What does this IIA try to achieve?

It’s important that those involved in making decisions about future maternity service transformation understand the full range of potential impacts that proposals could have on the local population. It is particularly important to understand the potential impacts on groups and communities who will be the most sensitive to service changes. This is the purpose of the EIA process.

IIAs are a key component of policy-making and help guide and appraise investment (HM Government (2011) Impact Assessment Overview). They have long been identified as a mechanism by which potential effects on health outcomes and health inequalities can be identified and revised before implementation.

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The aim is to explore the positive and negative consequences of different proposals and produce a set of evidence-based, practical recommendations, which can then be used by decision-makers to maximise the positive impacts and minimise any negative impacts. The wellbeing of the local communities is promoted and protected because, through the IIA, decision makers have the best possible information on which to base their decisions.

The BSW Service Redesign Steering Group requested an IIA of the proposed changes to maternity services. An IIA is also a requirement of the NHSE Service Reconfiguration process. The objectives of the IIA are to:

• Bring together all required impact assessment include Equality, Travel and Quality

• Understand the overall demography and the protected characteristic groups (as defined by the Equality Act 2010) of the different CCG populations affected.

• Undertake an Equality Impact Assessment, which is critical in supporting the CCGs in meeting their obligations under the Equality Act 2010:

• Understand the impacts on protected characteristic groups across the CCG populations through a programme of stakeholder engagement

• Identify which (if any) of the protected characteristic groups are more likely to be affected by the proposals due to their propensity to require different types of health services and what these impacts will be

• Where impacts are disproportionate for certain groups, consider opportunities for mitigating negative impacts and enhancing positive impacts

• Understand how the proposals impact on all elements of our population

Patient, service user and public engagement across BANES, Swindon and Wiltshire undertaken to date

We have informally consulted with more than 2,000 women across the BSW LMS to co-create our proposed future services for public consultation. Our LMS geography is complex with a mix of urban centres and rural locations. We are working towards our vision of delivering seamless maternity services that flow across organisational and geographic boundaries. We are also working with public health and local authority colleagues across the BSW STP to model the impact of future population growth and housing policy to understand our future demand requirements.

An initial assessment of the impact of our proposals on the three maternity systems - Bath, Swindon and Wiltshire - has been undertaken. It is envisaged that there will be limited impact on the Swindon facing system where women have positively fed back on their choices of delivering their baby in a consultant led unit, alongside unit or at home.

Women in Salisbury have limited birth options with a consultant led unit or home birth. We are therefore proposing that an alongside unit is created at Salisbury Hospital to offer greater choice and provide parity for our local population. The

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planned repatriation of military personnel and their families from overseas to South Wiltshire will increase birth numbers to provide additional sustainability for Salisbury services. Specific engagement with mothers and women who are likely to become pregnant was undertaken on three British Forces Germany military bases during 5-7 September 2018 and the feedback the women provided has been considered as part of our proposal.

We are proposing to consult with the public on plans to also create an Alongside Midwifery Unit at the RUH in Bath. This will be partly supported by resources released from reducing the number of Freestanding Midwifery Units in the RUH facing system where we are seeing an increasing trend of underutilisation. The aim of this proposal is to create parity for our population and ensure our resources are used efficiently. We want to ensure our services meet the needs of our local women and families. These changes will also help us to deliver our continuity of carer and personalised care and choice agendas. Our model of care will move on from historic bed based models to a new system where women and families will have antenatal and postnatal services provided closer to home.

As described above, further engagement and consultation on the actual proposals, together with the details of the Travel Impact Assessment and Equality Impact Assessment, will help to identify whether any equality groups/protected characteristics will be adversely affected by the proposals.

This document will therefore continue to be updated and adapted to include targeted and universal engagement findings throughout the period of the consultation. These findings will aid decision makers about whether to implement the proposals set out through the consultation.

Staff and User engagement and feedback from the RUH

Staff engagement

Over the first four months of 2017, the RUH Bath held focus groups in all clinical areas of the Maternity services.

The findings of the Kirkup report (2015) were presented to staff attending to generate discussions about maternity services requirements to ensure lessons were learnt and how as a service we could reduce the risk of any reoccurrence of the issues.

The staff who attended the focus groups were asked to consider:

• What keeps you awake at night? • What do we do well? • What should we do differently?

The aim was to capture an understanding from our staff regarding inequalities in both clinical and service provision. Was the right person doing the right job? What

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did they see the culture as? Is there a culture of professional challenge? And if not, why not?

As well as the focus groups, anonymous feedback boxes were left in the clinical areas for at least a month in order for staff to reflect on the issues and submit further information if required.

All of the areas engaged in the process - the anonymous feedback boxes were collected and only one unit had feedback in single figures.

Themes/suggestions for review identified by staff were:

• Review of booking procedure • Inequality of ante natal appointment times across the service • Pressure to include public health agendas and how to find the time • Safeguarding – time and increased requirements • How to ensure continuity • The need for a robust homebirth service • Concerns about the on call provision - each area trying to support own unit for

on call • Having to work in different areas of the service at short notice • Infant feeding support requirements - lack of ability to support women leading

to increased readmissions • The tongue tie service and number of referrals • Birth environment improvements • Inequality of midwife ventouse provision in birth centres • Increasing ward attenders in birth centres and blurring of boundaries between

community and acute unit • Staff scared they may make mistakes • Culture of fear

What we could do better:

• Continuity of care and carer • On call cover • Telephone triage in birth centres • Documentation and response to laboratory results • Use of birth centre post-natal beds – current under usage • Location of day assessment provision

During this process there was willingness and openness for staff to share their thoughts and feelings. There was a significant amount of feedback from areas regarding the unbalanced staff provision across the services. Both midwifery and support staff talked to the Matron and Patient Safety Manager about the ‘unfairness’ and ’inequity ‘of the workload across the units particularly at night.

Verbal feedback included:

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‘I find it difficult to work in a unit where you don’t do anything clinical or see a woman all night’.

‘We need the staff in the day to help with all of the increasing demands antenatally and postnatally’.

‘We don’t have enough staff to care for all the women but there are six midwives staffing areas that may not support one birth during the night shift, this seems very unfair’.

On some occasions the staff themselves stated that they could not see why all of the birth centres were supporting birthing facilities, as reviewing this would also support safer staffing in other areas.

Staff survey

In the staff survey, when asked about the job the staff were doing, areas of concern were raised under the following themes:

• Staff perception around lack of staff and resources • Not providing the standard of care that staff would personally like to provide. • Not being involved in deciding on changes introduced that affect my work area

/ team / department • Not being able to meet all the conflicting demands on my time at work.

Obstetrician feedback

Obstetricians who work within the service were also met with and the team agreed that modernising the service focussing on safety, equity and choice was paramount. The Consultant team was united in its view that organisational change was required and that providing appropriate levels of care by skilled staff was a priority. The service was required to be responsive to the choice that women were making as well as factoring in the changing demographic and population’s needs based on co morbidities.

Delivery Assessment Unit (DAU) provision

Staff identified that the current DAU based in the acute setting does not have sufficient capacity to manage the current workload and is inadequate for the needs of the service. An expansion of the service in opening times, numbers of beds and staff is urgently required. Policies and guidelines require updating as to which women will require DAU assessment and clear guidelines for women that maybe assessed in birth centres needs to be developed. This will significantly reduce the number of ‘ward attenders’ in birth centres.

Over a number of years the requirement for the provision of extra outpatient care above the planned care pathway has increased significantly. This is in response to

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national developments in evidence based practice, guidance from the Royal Colleges and the national institute of clinical effectiveness (NICE) as well as women’s expectations. In addition, the increase in women with complex needs and those with co-morbidities has increased this demand on this service.

The safe provision of day assessment services (DAU) is multifactorial and includes robust and effective guidelines, adequate building facilities to manage capacity, a staffing model that supports the provision of service required and direct access to obstetric staff who are senior enough to make rapid decisions regarding women’s care.

Who are our patients and public?

Data has been reviewed from a range of sources including Public Health England, the Office for National Statistics (ONS), the South West Clinical Network Maternity Dashboard and RightCare and based on this information; the following conclusions can be drawn.

The total population of BSW LMS is 894,065 (ONS 2016 mid-year estimates) of which there are around 250,000 women of child bearing age (15 to 49 years).

• Wiltshire is a predominantly rural area covering an area of 3,485 km2.and population density averages 140 people per km2. It is largely white-British population with few people from ethnic minorities. Access to maternity services varies considerably for women living in different parts of Wiltshire.

• Swindon is a large town covering an area of only 40 km2 and the average population density is 5,447 people per km2. The 2011 census showed population growth to be faster in Swindon than the England average and the population from minority ethnic groups nearly doubled in ten years.

• The B&NES area contrasts greatly in terms of density and diversity of population. The city of Bath accounts for approximately half the population and is 12 times more densely populated than North East Somerset. About 10% of the population are non-white-British. B&NES is one of the least deprived authorities in the country, ranking 247 out of 326.

Patient and public feedback and engagement - general

The National Maternity Review (2016 - the themes discussed in page 1 of this report) identified that using the voices of women and listening to their stories can help make improvements to maternity services. The maternity services view family feedback as an essential part of developing a responsive appropriate, kind and caring service.

Maternity services have a variety of tools to gather patient experience and feedback including Friends and Family Test (FFT), CQC Maternity Picker Survey, Birth Reflections, Compliments and Complaints. This information is regularly triangulated

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to gather themes, both positive and areas for improvement, to ensure priorities align with what our women and their families are telling us.

Local themes include:

• Quality of care – kindness, compassion, listening. • Continuity of Carer – antenatal and postnatal. • Better communication between teams / other health professionals. • Emotional wellbeing and support in the post-natal period.

CQC Inpatient Survey 2015 – RUH Bath

The CQC survey 2015 results are based on the responses of 159 mothers who gave birth at the Trust in February 2015. Feedback from the women and families overall was good and the services scored well in being cared for with respect and dignity and for the women having confidence and trust in the services. The areas identified as requiring further development were regarding continuity of care.

‘Feel like it would have been more beneficial to have seen the same midwife before and after the birth for improved continuity of care. Whilst every midwife I saw was great, a lot of time was wasted in my opinion. When they each had to ask about my history or check what I had been told already.’

Whilst the majority of the feedback focussed on the quality of the services received it is important to understand and respond to what families see as important factors in their pregnancy pathway.

CQC Regulatory inspection 2016

The Care Quality Commission (CQC) in March 2016 reported the RUH Maternity services had ‘thorough risk management and governance structures and processes in place. These linked risk and governance meetings at both departmental and trust level. This produced an effective flow of information from ward to board and vice versa.’ To enable the evidencing of a robust governance structure the team were able to demonstrate a culture of transparency and openness, triangulation of feedback from complaints and compliments, local incident reporting and themes, outcomes of incident investigations and verbal feedback from the maternity, obstetric and paediatric teams identified in the provision of care and services.

In Your Shoes

‘In Your Shoes’ events are planned listening events which took place through the LMS area as opportunities for staff to listen to women and families sharing their experiences of our care, and to work together to identify what would make the biggest positive difference to their experience and to list the priorities for improvement.

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We asked, ‘what are your priorities for improvements to our Maternity Services?’ and the responses are summarised below and provided pictorially in the word cloud below;

• Continuity of Care / Carer through antenatal and postnatal period. • Offer individual, personalised, women-centred care. • Improved communication between staff and with women and their families. • Increased provision for antenatal education to include emotional changes

after birth and how to care for a baby. • Positive staff attitudes. • Facilities to stay after birth at Frome Birthing Centre. • Better facilities available for partners. • Treat women and their families with respect and support choice • Ensure the care offered is consistent between families. • More services offered locally within community to enable greater choice. • Increased staffing levels to ensure high quality care is provided • Offer more support in early pregnancy i.e. drop ins / shorter gaps between

appointments. • Offer more Antenatal Education, including the basics of how to care for a

baby. • Ensure a consistent level of care and information are provided to all women.

There are clear similarities to the national picture and the priorities of Better Births: Safer Care, Personalised Care, and Continuity of Carer, Working across boundaries, Multi-professional working and Better Postnatal and Perinatal Mental Healthcare (Better Births).

Choice of Birth Location Audit

An audit, led by the maternity matron team, was undertaken in May 2015, with the aim to understand the reasons why low risk women choose to birth in the acute unit and understand the factors that influence local women’s choice of birth place. The

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results are multifactorial, some women chose Bath due to epidural availability, the possibility of transferring in labour was also an influencing factor and there were also external influence such as family preferences, peer, GP and Midwife advice.

MSLC Survey of Women’s Experience of Maternity Services

In April 2017 Public Health professionals worked together with service user representatives from the MSLC to develop and implement an online Place of Birth Survey. The survey focussed on what and/or who informs women’s decision about where to birth their baby and was targeted at women who were currently pregnant and those who had given birth within the last year. The week long survey received 850 responses from across the BSW area.

The respondents were from a fairly representative sample in terms of deprivation and there was a 50:50 split between those pregnant and those who had given birth in the last 12 months. The data was analysed, themes drawn out and the following recommendations made:

• Develop ways of engaging with partners and ensuring they have access to unbiased information to inform decision making around place of birth.

• Ensure unbiased information and discussion that includes the risks and benefits of all birthing options is offered to all expectant parents consistently across the Local Maternity System. To include identifying and agreeing use of an online tool, e.g. Which Choices.

• Actively promote positive birth stories and experiences to expectant parents and the wider community to promote positive birthing generally and to help break down misconceptions about certain birthing choices, such as birthing in the community.

• Engage with service users to gain a more detailed and deeper understanding of what aspects of birth environment affect their decision about where to birth.

• Adopt a similar methodology in the future to gather feedback from a representative sample of service users on issues related to maternal health and care.

Independent statistical evaluation of RUH service user survey responses

As part of the informal engagement work undertaken by The Royal United Hospitals NHS Foundation Trust (RUH), the Trust commissioned the Centre for Healthcare Innovation and Improvement at the University of Bath School of Management, to carry out a quantitative and qualitative analysis of a survey responses on the provision of maternity services in the RUH catchment area and to evaluate the specific model of service provision currently in use and to support through quantitative and other evidence any decisions around the strategic reconfiguration of the service. Over 790 service user responses were received. The final results were received in September 2017.

In addition, the following public events have been held:

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Stakeholder events

We held four informal face-to-face discussion groups:

Tuesday 14th February 2017 Oasis Boardroom, RUH Bath, Monday 27th February 2017 Victoria Hall, Church Street, Radstock Tuesday 7th March 2017 Assembly Hall, Market Place, Melksham Tuesday 14th March 2017

Wednesday 5th September 2018

Thursday 6th September 2018

Friday 7th September 2018

Wiltshire Council, County Hall, Trowbridge

BFG Military Base, Bielefeld, Germany

BFG Military Base, Paderborn, Germany

BFG Military Base, Gutersloh, Germany

We invited service users and their families, Healthwatch, GPs and commissioners to attend, advertising widely through social media, flyers in GP practices, child health centres. A list of stakeholders receiving invitations to the informal discussion groups follows:

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Key findings of the survey analysis

The questionnaires were circulated widely across Wiltshire, Somerset and BANES, during an engagement period that ran from 1st February through to 31st March 2017. In total 791 people, male and female aged 18 plus, completed the questionnaires. Both quantitative and qualitative methods were used to analyse the responses in a systematic and rigorous manner.

Although not designed to solicit a direct evaluation of the quality of the service experience, the analysis revealed that service users had a generally positive albeit mixed experience of the acute maternity and community services. When asked of what aspects of care service are deemed to be important in general, it emerged that service users wanted to be treated with compassion and within a service that provides personalised care.

Familiarity with the midwife was also seen very important but also knowing that there is specialised care available was also seen as important. Another finding is the importance service users placed on availability of resources in general. Most of the concerns raised in the survey related to the perceived low availability of a range of resources.

Travel Impact Assessment

The data from Travel Impact Assessments (1) and (2) is set out as an accompaniment to this document.

The details identified through the assessments will help to identify whether any equality groups/protected characteristics will be adversely affected by the proposals.

This document will continue to be updated to include the consultation findings. These findings, alongside the full results of the consultation, will aid decision makers about whether to implement the proposals set out through the consultation.

Phase 1 of the Travel Impact Assessment (TIA) assessed travel times at a population level for peak and off-peak travel times. Phase 2 of the TIA has assessed travel times based on previous years birth activity (2015-16 to 2017-18) to provide much greater detail on the potential impact, or otherwise, of our proposed service change to move from four to two Free-standing Maternity Units.

Phase 2 of the TIA has also been commissioned from South Central West Commissioning Support Unit (SCW CSU).

In order to complete TIA phase 2, birth data for all three CCGs across BANES, Swindon and Wiltshire, plus a number of other bordering CCGs (where women have given birth in one of the three hospitals within the BANES, Swindon and Wiltshire

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boundary) has been analysed, to assess the impact on women who use the maternity services covered by these proposals for change.

Data sharing agreements have been obtained for the three CCGs within Wiltshire, BaNES and Swindon - as well as Somerset, South Gloucestershire and West Hampshire. Births for the Military commissioner have also been included in the analysis. It has not been possible to obtain data sharing agreements for all bordering CCGs to support this analysis; however, it is felt that sufficient activity data has been included to provide a valid assessment of any impact of the proposals on travel times. This is due to the geographical locations for the proposed changes to the south and west of the BANES, Swindon and Wiltshire geography.

A summary of the coverage as a proportion of total births is provided in this document, which illustrates that 89.8% of the total number of births across BANES, Swindon and Wiltshire have been included in the analysis. This breaks down to 97.7% for the Royal United Hospital, 83.7% for Great Western Hospital and 85.3% for Salisbury Foundation Trust.

Scope of analysis

The CSU has been commissioned to provide GIS and mapping support to BSW CCGs and provider trusts in relation to their maternity service reconfiguration programme.

The work programme has been split into two main sections:

• TIA 1 – Travel Impact Assessment – Resident population analysis • TIA 2 – Travel Impact Assessment – Maternity activity analysis

TIA 1 – Travel Impact Assessment – Resident population analysis

Methodology

For phase 1, SCW CSU has undertaken travel analysis for one mode of transport - driving at peak time and off-peak, in order provide a view on the likely travel impacts based on the particular scenarios. Travel maps have been created to show travel isochrones, typically in 15 minute bands (0-15, 15-30, 30-45, 45-60, and 60-75). These travel bands have then been used to identify the resident populations for each band. This has been undertaken for women of child bearing age, e.g. 15-45 and includes populations that extend outside of the BANES, Swindon and Wiltshire geographic area using BSW LMS maternity services. The catchment boundary is shown in figure 1 below. Whilst this programme of work is being undertaken for BANES, Swindon and Wiltshire (BSW), the boundary of the Travel Impact Analysis has been set wider than the geographic catchment as the three hospital Trusts provide services for women

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and families outside of the BSW footprint. Therefore, the catchment boundary has been set to reflect this. Figure 1: Boundary area for Travel Impact Assessment

The analysis has assessed impact by travel bands in 15 minute intervals and looked at peak Travel times: 7am - 9.30am and 4pm – 7pm and off-peak Travel times: 9pm. The travel analysis is based on iGeolise which is a recognised travel time platform and mapping of driving time changes has been undertake for 16 scenarios.

Scenario modelling

The proposed case for change is to move from four to two freestanding midwifery units (FMUs) based on the options appraisal scoring process as described in Chapter 5 of the Pre-consultation Business Case. However, to ensure a full understanding of the possible impact on travel times, scenario modelling has been undertaken for five overall scenarios; combinations of 4, 3, 2, 1 and 0 Freestanding Midwifery Units.

This has also provided comparative data to ensure our proposal for change will not have a significantly greater impact on travel times, than other options which were excluded through the ‘developing our proposal’ process.

For each of these scenarios, there are a number of combinations (as set out in the table below). In all there are 16 combinations and travel maps have been created to assess the impact of changing the number of FMUs within the geographical area for both peak and off-peak driving times.

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Table 1: Scenarios used for Phase 1 of the Travel Impact Assessment

Scenario

RUH, GWH, SDH,

Cossham Trowbridge Chippenham Frome Paulton No of FMUs Scenario 1 4 Scenario 2.1 3 Scenario 2.2 3 Scenario 2.3 3 Scenario 2.4 3 Scenario 3.1 2 Scenario 3.2 2 Scenario 3.3 2 Scenario 3.4 2 Scenario 3.5 2 Scenario 3.6 2 Scenario 4.1 1 Scenario 4.2 1 Scenario 4.3 1 Scenario 4.4 1 Scenario 5 0 Count - 8 8 8 8 -

Data assumptions

• Publically available data such as the ONS Census has been used • ONS 2016 at Output Area - represents population of around 400 people • Female population aged 15-49 (approx. 250,000 women) • Catchment boundary used is the BSW CCGs plus known catchment of three

hospitals – see Figure 1 above.

Outputs from Travel Impact Analysis (Phase 1)

For both peak and off-peak driving times, 16 maps have been created to illustrate the travel time zones and travel impact for each of the various scenarios. A complete set of the maps plus the boundary map can be provided on request.

Summary tables detailing the cumulative percentage of patients within the travel zones are provided in the table below as a comparator.

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Table 2: Cumulative percentage of patients within the travel zones - Peak

Peak Drive Time Scenario 0-15 Mins 0-30 Mins 0-45 Mins 0-60 Mins

Scenario 1 33.0 83.4 99.9 100

Scenario 2.1 27.4 82.6 99.9 100

Scenario 2.2 29.9 83.0 99.8 100

Scenario 2.3 26.9 82.6 99.9 100

Scenario 2.4 27.4 79.5 99.7 100

Scenario 3.1 24.3 80.3 99.8 100

Scenario 3.2 21.8 78.7 99.7 100

Scenario 3.3 24.2 79.1 99.6 100

Scenario 3.4 21.3 81.8 99.9 100

Scenario 3.5 23.2 79.8 99.5 100

Scenario 3.6 21.3 72.8 99.7 100

Scenario 4.1 18.6 76.4 99.6 100

Scenario 4.2 17.6 72.6 99.1 100

Scenario 4.3 15.7 72.0 99.7 100

Scenario 4.4 17.6 65.6 97.8 100

Scenario 5 12.0 56.3 96.1 100

Table 3: Cumulative percentage of patients within the travel zones – Off-Peak


Scenario 1 40.2 93.7 100 -

Scenario 2.1 33.7 93.4 100 -

Scenario 2.2 36.6 93.3 100 -

Scenario 2.3 34.3 93.7 100 -

Scenario 2.4 33.8 92.9 100 -

Scenario 3.1 30.1 91.7 100 -

Scenario 3.2 27.4 92.6 100 -

Scenario 3.3 30.3 92.4 100 -

Scenario 3.4 27.9 93.4 100 -

Scenario 3.5 29.2 92.0 100 -

Scenario 3.6 27.5 88.5 100 -

Scenario 4.1 23.7 90.8 100 -

Scenario 4.2 22.6 86.5 99.9 100

Scenario 4.3 21.0 88.2 100 -

Scenario 4.4 22.3 83.7 100 -

Scenario 5 16.5 71.8 99.7 100.0

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Observations from Travel Impact Analysis (Phase 1)

Based on the first phase of the travel impact analysis, the following observations on the travel impact assessment can be made:

• For Scenario 1 “as is”, a total of 83.4% of the female population are within 30 minutes of a birth unit (based on peak driving times). This increases to 93.7% off-peak.

• The impact of the various scenarios on the percentage of the female population within 30 minutes during peak travel times ranges from 56.3% (Scenario 5) to 83.0% (Scenario 2.2). For off peak, this ranges from 71.8% (Scenario 5) to 93.7% (Scenario 2.3).

• For the proposed case for change to move from four to two FMUs, there are six potential scenarios and the percentage of female population aged 15-49 within 30 minutes of two FMUs ranges from peak – 72.8% to 81.8% and off peak – 88.5% to 93.4%.

• Scenario 3.4 with two FMUs located in Chippenham and Frome provides the best coverage in terms of travel time within 30 minutes, both for peak and off-peak travel times and is not significantly less than that of 4 FMUs.

• Within 30 minutes

Scenario 1 “as is”

Scenario 3.4 Chippenham &

Frome

Variance

Peak 83.4% 81.8% 1.6% Off-peak 93.7% 93.4% 0.3%

• For high risk women who have to travel to one of the three Obstetric Units for

birth based on clinical need, only 56.3% are within 30 minutes of an Obstetric unit (Scenario 5) during peak travel times and 73.0% off peak.

TIA 2 – Travel Impact Assessment – Resident population

Phase 1 of the TIA assessed travel times at a population level for peak and off-peak travel times. Phase 2 of the TIA has assessed travel times based on previous years birth activity (2015-16 to 2017-18) to provide further granularity on the potential impact, or otherwise, of our proposed service change to move from four to two FMUs.

The travel impact assessment (Phase 2) has also been commissioned from South Central West Commissioning Support Unit (SCW CSU).

Data sharing agreements

In order to complete the phase 2 TIA, birth data for all three CCGs in the BSW STP plus a number of other border CCGs, where women have given birth in one of the three providers within the STP boundary, has been analysed to assess the impact on women who use the maternity services covered by these proposals for change.

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Data sharing agreements have been obtained for the three CCGs within Wiltshire, BaNES and Swindon - as well as Somerset, South Gloucestershire and West Hampshire. Births for the Military commissioner have also been included in the analysis. It has not been possible to obtain data sharing agreements for all bordering CCGs to support this analysis; however, it is felt that sufficient activity data has been included to provide a valid assessment of any impact of the proposals on travel times. This is due to the geographical locations for the proposed changes to the south and west of the STP footprint (See: Figure 1 above).

A summary of the coverage as a proportion of total births is provided below which illustrates that 89.8% of the total provider births have been included in the analysis. This breaks down to 97.7% for the RUH, 83.7% for GWH and 85.3% for SFT.

Table 3: Data Sharing for Travel Impact Assessment – births for 2017/18

CCGs 2017/18 RUH GWH SFT Total 1 NHS Wiltshire 2,013 908 1477 4,398 2 NHS BANES 1,606 1,606 3 NHS Somerset 689 689 4 NHS South Gloucestershire (part of BNSSG) 185 185 5 Swindon CCG 2756 2,756 6 Gloucestershire CCG 275 275 7 Berkshire West CCG 188 188 8 Oxfordshire CCG 60 60 9 Dorset CCG 306 306

10 West Hampshire CCG 233 233 National commissioning hub - Military 214 214 Out of area - RUH 105 105 Out of area - GWH 190 190 Out of area - SFT 25 25 Total 4598 4377 2255 11,230

Data for TIA phase 2 4,493 3,664 1,924 10,081

Percentage of births 97.7% 83.7% 85.3% 89.8%

Methodology

Records of individual births between April 2015 and March 2018 within BSW, Somerset, Bristol, North Somerset and South Gloucester and West Hampshire CCGs were sourced by SCW CSU from in-house data warehouses. The records included information on the mother's Census Output Area (COA) of residence and also whether the birth was classified as high or low-risk pathways.

A total of 29,588 recorded births were provided for the three year period (births from 01/04/2015 to 31/03/2018). Of these, it was not possible to map 310 records as they did not have the required geographic information.

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In addition, a further 214 births during 2017-18 were reported for which the parents were based at the military base at Tidworth. Exact locations were not provided due to data protection regulations but were described as all being within two miles of Tidworth. This total was multiplied by three to estimate the number of such births during 2015-18. These births were attributed evenly amongst the COAs within two miles of Tidworth. 75% of these births were classified as high-risk and 25% as low-risk based on advice from SCW CSU colleagues.

Together with the 632 births related to the military base at Tidworth there were a total of 29,920 spatially mapped births in this area during the time-period. Of the mapped births 23,121 were classified as high-risk and 7,926 as low-risk. The accessibility of the different scenarios has also been summarised for each classification.

In order to classify births as high or low risk, RUH informatics had discussions with Obstetric clinicians and produced a list of diagnosis codes and procedure codes indicating high risk pathways. These codes were then used to identify high and low risk births from the dataset obtained. If any of these codes presented in the delivery spell record in the Secondary Uses Service (SUS)2 for the patient, the record was classified as high risk. If none of these codes presented in the delivery spell record, the record was marked as low risk.

The recorded births were mapped against the residence Census Output Area (using Population Weighted Centroids) and spatially related against the travel-time isochrones in order to provide cumulative counts and percentages within travel-time zones for the different scenarios.

Scenario Modelling

The same 16 scenarios as undertaken in TIA Phase 1 have been used (see Table 1 above). The difference with the phase 2 analysis is that the travel impact has been analysed for high risk and low risk pathways separately, as well as overall.

Peak and Off-peak Driving Times analysis for the 16 scenario combinations has been undertaken and again, the cumulative number and percentage of patients within each of the travel zones has been provided for all births, high-risk and low-risk births).

Analysis has been run on data for three years (2015-2018) as using a three year data trend will smooth out any significant variation.

Data assumptions

2 The Secondary Uses Service (SUS) is the single, comprehensive repository for healthcare data in England which enables a range of reporting and analyses to support the NHS in the delivery of healthcare services.

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• Data source - recorded births supplied by SCW CSU, mapped to Census Output Areas (using Population Weighted Centroids).

• Travel zones generated using Igeolise travel-time analysis. • Spatial distribution of births against travel zones analysed using FME point-in-

area analysis. • Travel-time isochrones to represent areas of accessibility within 15 minute

journey time bands were generated for 16 maternity service scenarios. • Areas of accessibility were calculated based on driving at peak times (7am to

9.30am and 4pm to 7pm) and off-peak times (9pm). Source: generated using iGeolise travel time analysis.

Outputs from Travel Impact Analysis (Phase 2)

For both peak and off-peak travel times, 16 maps have been created to illustrate the travel time zones and travel impact for each of the various scenarios for the three years of data. A complete set of the maps can be provided on request.

A summary table detailing the cumulative percentage of patients within the travel zones is provided in the table below as a comparator.

The resident population analysis uses actual birth date for the financial years 2015-16, 2016-17 and 2017-18. Due to clinical necessity for high risk women to travel to one of the three Obstetric Units, in terms of travel analysis, scenario 5.0 – three Obstetric Units - illustrates the travel times for women on a high risk pathway.

Table 4: Travel times for high risk women – three obstetric units – Peak

Private Vehicle

Scenario 5 - RUH, GWH, SDH, Cossham

All Births High-risk Births Low-risk Births Peak Time No. Percentag

e No. Percentag

e No. Percentag

e 0-15 Mins 3,446 11.5 2,668 12.0 778 10.1 0-30 Mins 15,954 53.3 12,079 54.4 3,875 50.1 0-45 Mins 28,755 96.1 21,336 96.2 7,419 95.9 0-60 Mins 29,907 100.0 22,177 100.0 7,730 100.0

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Table 5: Travel times for high risk women – three obstetric units – Off-peak

Private Vehicle

Scenario 5 - RUH, GWH, SDH, Cossham

All Births High-risk Births Low-risk Births Peak Time No. Percentag

e No. Percentag

e No. Percentag

e 0-15 Mins 4,551 15.2 3,510 15.8 1,041 13.5 0-30 Mins 21,013 70.2 15,845 71.4 5,168 66.8 0-45 Mins 29,779 99.5 22,078 99.5 7,701 99.6 0-60 Mins 29,912 100.0 22,181 100.0 7,731 100.0

For high risk women who have to travel to one of the three Obstetric Units for birth, 54.4% are within 30 minutes of an Obstetric unit (Scenario 5) for peak travel times and 71.4% for off-peak. This is compared to 56.3% (peak) and 73.0% (off peak) for TIA Phase 1.

For phase 2 TIA, the impact on ‘low risk’ maternity activity has been assessed separately, excluding high risk pathways, as any proposed changes to the number of or location of FMUs will not have an impact on high risk pathways as these will continue to access the obstetric units based on clinical need.

Below is a summary of the cumulative percentage of ‘low risk’ women within the travel zones based on three years data:

Table 6: Cumulative percentage of ‘low risk’ women within the travel zones – Peak


Scenario 1 41.6 87.3 99.7 100.0 Scenario 2.1 33.2 85.9 99.7 100.0 Scenario 2.2 36.1 87.0 99.7 100.0 Scenario 2.3 32.1 86.5 99.7 100.0 Scenario 2.4 34.0 83.0 99.7 100.0

Scenario 3.1 27.8 83.5 99.6 100.0 Scenario 3.2 25.6 81.6 99.6 100.0 Scenario 3.3 28.5 82.7 99.7 100.0 Scenario 3.4 23.7 85.1 99.7 100.0 Scenario 3.5 26.0 83.4 99.6 100.0 Scenario 3.6 24.5 74.2 99.7 100.0

Scenario 4.1 20.2 79.2 99.5 100.0 Scenario 4.2 17.7 72.3 99.1 100.0 Scenario 4.3 16.1 72.9 99.6 100.0 Scenario 4.4 18.4 64.3 98.0 100.0 Scenario 5 10.1 50.1 95.9 100.0

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Table 7: Cumulative percentage of ‘low risk’ women within the travel zones – Off-Peak

Off-Peak Drive Time Scenario 0-15 Mins 0-30 Mins 0-45 Mins 0-60 Mins

Scenario 1 49.3 94.4 99.9 100.0 Scenario 2.1 40.1 93.4 99.9 100.0 Scenario 2.2 43.3 94.1 99.9 100.0 Scenario 2.3 40.2 94.4 99.9 100.0 Scenario 2.4 40.8 93.9 99.9 100.0

Scenario 3.1 33.9 91.8 99.9 100.0 Scenario 3.2 31.5 92.8 99.9 100.0 Scenario 3.3 34.8 93.6 99.9 100.0 Scenario 3.4 31.0 93.4 99.9 100.0 Scenario 3.5 32.1 92.7 99.9 100.0 Scenario 3.6 31.0 89.2 99.9 100.0

Scenario 4.1 25.3 91.2 99.9 100.0 Scenario 4.2 22.7 83.9 99.7 100.0 Scenario 4.3 21.8 88.2 99.9 100.0 Scenario 4.4 22.9 82.9 99.9 100.0 Scenario 5 13.5 66.8 99.6 100.0

Observations from Travel Impact Analysis (Phase 2)

Based on the second phase of the travel impact analysis, the following observations on the travel impact assessment can be made:

• For Scenario 1 “as is”, 87.3% of women who give birth within a three year period were within 30 minutes of a birth unit based on peak travel times. This was 94.4% off-peak.

• For peak travel times, the impact of the various scenarios on the percentage of the female population within 30 minutes ranges from 50.1% (Scenario 5) to 87.0% (Scenario 2.2). For off-peak travel times, it ranges from 66.8% (Scenario 5) to 94.4% (Scenario 2.3).

• For the proposed case for change to move from four to two FMUs, there are six potential scenarios and the percentage of women who gave birth (over a three year period) who were within 30 minutes of two FMUs ranges from 74.2% to 85.1% (peak times) and 89.2% to 93.6% (off peak).

• Scenario 3.4 (two FMUs located in Chippenham and Frome) provides the highest percentage coverage in terms in terms of travel time within 30 minutes at 85.1% during peak travel times. This is compared to 87.3% for 4 FMUs (a 2.2% variance).

• Scenario 3.3 (two FMUs located in Trowbridge and Paulton) provides the highest percentage coverage in terms in terms of travel time within 30 minutes at 93.6% during off-peak travel times. Scenario 3.4 (FMUs located in Chippenham and

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Frome) is 93.4%, which is a 0.2% variance. Neither of these scenarios is significantly less than that of 4 FMUs, which is 94.4% (between 0.8%-1.0% variance).

• For high risk women who have to travel to one of the three Obstetric Units for birth, 54.4% are within 30 minutes of an Obstetric unit (Scenario 5) during peak times and 71.4% off peak.

Catchment areas for FMUs / AMUs / Obstetric Units

An assessment of catchment areas for FMUs and AMUs has also been undertaken to help identify how much low risk activity might be provided in future to each birth location based on their 'catchment'. The basic assumption for low risk activity would be that they are likely to have their birth at their local (closest) FMU or AMU.

Methodology

Records of individual births from 2015-16, 2016-17 and 2017-18 within BSW, Somerset, BNSSG and West Hampshire CCGs were sourced by NHS South Central and West Commissioning Support Unit (SCWSU) from in-house data warehouses. The records included information on the mother's Census Output Area of residence, the maternity unit where the birth took place and also whether the birth was High or Low-risk.

The recorded low-risk births were mapped against the residence Census Output Area (using Population Weighted Centroids) and spatially related against the catchment areas in order to enable analysis of the extent to which the closest delivery unit was chosen and whether any particular units were favoured.

Travel catchment zones3 were generated for the maternity units in the current configuration and in scenarios 3.1 to 3.6 – combinations of two FMUs.

Assumptions:

• Catchment boundaries calculated using peak drive time route to nearest maternity site (by time) in each scenario

• Source: RouteFinder • ONS 2016 MYE at Output Area (OA) - Females aged 15 to 49 • Population calculations are based on the population weighted centroid of each

OA that are located within the catchment boundary.

Outputs from the Catchment Analysis

Two outputs from the catchment analysis were produced:

3 Representing the area from within which a particular maternity unit is the closest provider (based on journey time by private vehicle)

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Current Scenario Activity

This provides a count of the low-risk births that took place at each provider and compares this against the number of births that might have been expected each location, based on the mothers' residences and the travel catchment area of the unit.

Table 8 below shows the number of low risk births at each of the units in the LMS and the expected number of low risk births based on the unit catchment. The highlighted cells indicate those maternity units where the actual activity was less than might be expected based on the travel catchment area of the unit.

Table 8: Low risk births by Birth Unit compared to expected catchment

Hospital Name

Low-Risk Births at hospital (2015-

18)

Mothers living within hospital catchment

area (low-risk recorded births 2015-

18) THE GREAT WESTERN HOSPITAL 2355 2078 ROYAL UNITED HOSPITAL 2389 830 SALISBURY DISTRICT HOSPITAL 900 771 CHIPPENHAM HOSPITAL 554 1166 FROME COMMUNITY HOSPITAL 513 714 PAULTON MEMORIAL HOSPITAL 322 842 TROWBRIDGE HOSPITAL 530 1033 COSSHAM HOSPITAL N/A 129

Table 9 shows the ratio of recorded births at each unit compared to the number of low risk births within the catchment. Again, the highlighting indicates those maternity units where the actual activity was less than might be expected based on the travel catchment area of the unit.

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Table 9: Low risk births by Birth Unit showing ratio compared to expected catchment

Hospital Name

Low-Risk Births at hospital (2015-

18)

Ratio of recorded births at hospital to number of mothers resident in catchment area

THE GREAT WESTERN HOSPITAL 2355 1.1 ROYAL UNITED HOSPITAL 2389 2.9 SALISBURY DISTRICT HOSPITAL 900 1.2 CHIPPENHAM HOSPITAL 554 0.5 FROME COMMUNITY HOSPITAL 513 0.7 PAULTON MEMORIAL HOSPITAL 322 0.4 TROWBRIDGE HOSPITAL 530 0.5

Scenario Activity Counts

This provides a count of the numbers of mothers resident within the catchment zone of each hospital under the different scenarios for two FMUs (Scenarios 3.1 to 3.6). Based on the maternal residence for the recorded low-risk births 2015-2018 it shows the likely catchment of low risk births for each unit under the six different configurations for two FMUs.

Table 10: Mothers living within hospital catchment area under the different proposed scenarios for two FMUs (based on location of low-risk recorded births 2015-18)

Numbers resident in catchment – Low risk births

Hospital Name

Low-Risk Births

at hospital (2015-18)

Scenario 1

(current)

Scenario 3.1

Scenario 3.2

Scenario 3.3

Scenario 3.4

Scenario 3.5

Scenario 3.6

THE GREAT WESTERN HOSPITAL 2,355 2,078 2,078 2,301 2,301 2,079 2,079 2,694 ROYAL UNITED HOSPITAL 2,389 830 1,446 1,227 899 1,165 1,050 1,140 SALISBURY DISTRICT HOSPITAL 900 771 806 771 806 771 824 771 CHIPPENHAM HOSPITAL 554 1,166 1,166 N/A N/A 1,469 1,974 N/A FROME COMMUNITY HOSPITAL 513 714 N/A 1,226 N/A 1,948 N/A 1,987 PAULTON MEMORIAL HOSPITAL 322 842 N/A N/A 900 N/A 1,507 842 TROWBRIDGE HOSPITAL 530 1,033 1,936 1,907 2,528 N/A N/A N/A COSSHAM HOSPITAL N/A 129 131 131 129 131 129 129

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Observations from catchment modelling

Based on the catchment analysis for low risk births, the following observations can be made:

• The analysis of women with a low risk birth shows that high numbers of women whose closest maternity unit option is one of the FMUs are nevertheless choosing one of the Obstetric Units to give birth in.

• The ratio of recorded births at FMUs to number of mothers resident in catchment area ranges from 0.4 (Paulton) to 0.7 (Frome).

• The ratio of recorded births at hospital to number of mothers resident in

catchment area for is particularly marked in the case of RUH Bath which is 2.9 compared to 1.1 and 1.2 respectively for Swindon and Salisbury. This illustrates that the Obstetric Unit in Bath is being chosen by a high number of women with a low risk birth who reside in other locations where there are FMUs.

• It is also worth noting that the travel catchment area for RUH Bath is

geographically small due to the central location.

• The scenario analysis of likely future catchment areas for the FMUs based on reducing from four to two FMUs shows reasonable even splits of catchment for two FMUs in Scenarios 3.1, 3.2, 3.4 and 3.5.

• The catchment splits between the two FMUs in Scenarios 3.3 and 3.6 are

significantly skewed e.g. Scenario 3.3 shows Paulton with a catchment of 900 compared to Trowbridge with a catchment of 2,528.

Vulnerability and accessibility analysis

Further analysis of the optimum options has been undertaken to assess impact of proposed change in terms of high levels of deprivation, poor accessibility and high levels of activity (high risk). It has also considered the Census data on 'access to car' statistics, available at Lower Super Output Area (LSOA) level. This is included as part of the Integrated Impact Assessment, which incorporates the Quality Impact Assessment (QIA), Equality Impact Assessment (EIA) and the outputs from the Travel Impact Assessment (TIA) described in this chapter.

Future demand modelling

A number of future modelling assumptions have also been undertaken to stress test the proposals for change to ensure our plans are robust and will deliver the proposed improvements now and in the future. The tests that have been applied are:

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• Population growth – UK wide population growth statistics as well as local based figures, where known, have been utilised to assess the impact on the proposed birth locations into future years.

• Housing growth - data from the Local Authority Local Plans has been modelled to assess impact of these plans on our proposals.

• Service changes based on proposal – assessment of the impact on the

distribution of birth activity by modality as a result of the proposed changes.

Observations from future modelling

A detailed assessment on the transition plan for our proposal for change are set out in Chapter 6 of the pre consultation business case. In summary, the observations on future modelling as are follows:

• Based on the expected population growth (based on ONS projections) and the anticipated repatriation of Military personnel in Salisbury, the number of births will increase by 375 across the LMS footprint by 2023/24.

• With the exception of this population growth, it is assumed the overall activity volumes will not change as a result of any proposed change in service provision.

• However, it is anticipated that there will be an impact on the distribution of birth activity by modality as the proposals for change are delivered.

• The expected changes in activity levels between Obstetric Units, AMUS, FMUs and home birth have been modelled by year over the period. At the end of the transformation programme, there will be an anticipated shift of low risk activity out of the obstetric unit to the AMUs and an increase in the numbers of home birth.

• It is also assumed that women choosing one of current 4 FMUs will continue to choose one of 2 FMUs, thereby increasing the utilisation in the remaining two FMUs. This will be supported by adjustments to the workforce model and improvements to the birth environments in the FMUs.

• These proposed changes will improve the capacity available to match the demand and ensure we can accommodate future population growth beyond the planning period, be able to respond to growing demand for high risk women and provide greater equity in choice of place of birth across the LMS footprint.

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Independent Travel Impact Analysis – Bath Centre for Healthcare Innovation and Improvement team, Bath University

Prior to the commencement of the LMS Transformation Programme, the RUH had undertaken some informal engagement on the services provided by the hospital. As part of this work, the RUH commissioned some independent analysis from the Bath Centre for Healthcare Innovation and Improvement team, Bath University to look at the impact on travel times of potential changes to the provision of Maternity services.

The team were also commissioned to analysis the questionnaire outputs of the informal engagement RUH undertook.

Aim of the location analysis

The aim of the location analysis commissioned was:

• To evaluate the current model of service provision and to support through quantitative and other evidence any decisions around the strategic reconfiguration of the service.

• To conduct a location analysis for maternity services within the catchment area of RUH using advanced modelling techniques and specialised software developed by the Bath Centre for Healthcare Innovation and Improvement team at Bath University.

The modelling was based on optimising the geographical location of birthing centres using the estimates of demand, travel times and other factors included in the data such as socioeconomic status.

Methodology

The analysis was conducted using software developed by University of Bath researchers based on sophisticated mathematical optimisation techniques. The location of a service user was determined by the Middle layer Super Output Areas (MSOAs) according to their location by postcode. The latter information was not provided to the research team due to data confidentiality reasons, and as such MSOA was the finer level of geographical detail the analysis could be performed at.

The objective of the optimisation algorithm, which was calculated for each scenario, is to minimise the sum of the distances from each MSOA to the closest facility, weighted by the demand of the MSOA as well as the deprivation index associated with the MSOA. This objective function aims to find solutions in which the facilities are closer to the MSOAs with higher populations and higher deprivation indices.

All the calculations were performed based on the population-weighted centroids of the MSOA as provided by the Office of National Statistics (ONS).

The optimisation of location was performed on the distance of the shortest driving route (in other words, the distance of the quickest route).

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The results are mathematically “optimal” but not so in a practical sense. For example, each solution assumes that service user will be referred and indeed attend the facility that is optimally allocated to them.

Modelling Assumptions

The following modelling assumptions were applied to the analysis:

• All models assume that the service would retain an obstetric unit located in Bath due to the clinical adjacencies to other clinical services e.g. theatres, anaesthetics, NICU

• Travel time in minutes were used rather than fastest travelling route represented in miles

• The scenario for no standalone birth centres was not considered as if was felt this would significantly reduce choice options of services provided

• In all of the scenarios explored, RUH was the only service which is to be retained at its original location and was not to be removed from the solution.

• MSOAs were used to calculate the Index of Multiple Deprivation (IMD) for each location.

• Calculations did not include any capacity considerations associated with each facility, only demand for services.

Scenario Modelling

A total of eight scenarios were modelled to assess the impact on birth activity. A description of the scenarios is set out in the table below:

Table 11: Scenarios modelled for birth locations

No. Scenario description 1 Deliveries All deliveries (low and high risk) and as is locations for all existing facilities 2 Low risk deliveries, all facilities (existing locations 3 Low risk deliveries, acute unit plus 3 additional community facilities (existing locations) 4 Low risk deliveries, acute unit plus 2 additional community facilities (existing locations) 5 Low risk deliveries, acute unit plus 1 additional community facility (existing locations) 6 Low risk deliveries, acute unit as is and 3 additional community facilities anywhere 7 Low risk deliveries, acute unit as is and 2 additional community facilities anywhere 8 Low risk deliveries, acute unit as is plus 1 additional community facility anywhere

Outputs from Travel Impact Analysis

Scenario 1, depicted in Figure 2, reflects the current location of birthing centres and which of these existing centres service users should ideally be referred to, based on fastest path from the population centre point of their MSOA and the deprivation of the MSOA.

Figure 2: Map of scenario 1 illustrating current locations of facilities in an optimal (hypothetical) scenario of demand assignment

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Scenario 2 also reflects the current situation, but looking only at a subset of low risk pregnancies. As Figure 3 depicts, the scenario gives an almost identical map to scenario 1. This is an expected result, since data shows that most deliveries happen in RUH despite the risk classification.

Figure 3: Scenario 2. Demand allocation of low risk births in an optimal (hypothetical) scenario of demand assignment

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Scenario 4 investigates which facilities to retain if two facilities were not part of the optimal solution, subject to the assumptions listed in scenario 3. Figure 4 depicts the result, with Trowbridge and Paulton not part of the optimal solution as recommended by the optimisation algorithm and subject to the limiting assumptions mentioned earlier.

Detailed optimisation results are shown in Table 7 below, with each combination of birthing facilities removed from the solution in turn. Removing Paulton and Trowbridge had the smallest impact in the value of objective function (37%), indicating why it was deemed the best combination to be excluded by the algorithm.

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Figure 4: Scenario 4, Low risk births with only two additional community facilities

Table 12: Effect on objective function value of leaving two community facilities out of the model

Facilities excluded Estimated difference None (Scenario 2) Baseline Chippenham, Trowbridge +63% Chippenham, Paulton +41% Chippenham, Frome +48% Trowbridge, Paulton +37% Trowbridge, Frome +65% Paulton, Frome +50%

Note: the bigger the difference from baseline scenario the worse the outcome

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Observations from Bath University travel impact analysis

• In every scenario in which the number of facilities was reduced, the objective function value (as estimated by the optimisation algorithm) is expected to increase, pointing towards longer travel distances. This is to be expected as service users, on average, would have to travel farther to access fewer facilities.

• In the hypothetical scenario of having three facilities in total (Scenario 4, one acute and two elsewhere), excluding Trowbridge and Paulton from the optimal solution is preferable to any other combination. This is because the pair was associated with the smallest estimated increase in the results (37%), with next closest combination being Chippenham and Paulton (41%).

• In the case of three birthing facilities in total (as in the point above), there is a difference, albeit a small one, between existing locations and choosing entirely new hypothetical locations for the two community facilities (Scenarios 4 and 7, 37% compared to 34 %) indicating that existing facilities are relatively well placed.

It should be noted that the optimal locations for antenatal and postnatal activity (outpatient facilities) was also included in the Bath University analysis commissioned by the RUH. However, following the informal engagement and develop of the proposals for change, no changes to the locations of the current provision of antenatal and postnatal care are included as part of this proposal, therefore, the outputs of this analysis have not be referred to within this chapter.

The full report from the Bath University can be found in appendix 5.9.

Travel Impact Assessment summary outputs

Based on all of the travel impact analysis described in this chapter, a summary of conclusions is provided in the table below:

Table 13: Summary conclusions from Travel Impact Assessments

Travel Impact Assessment Summary conclusions CSU TIA Phase 1 - Peak Optimum option – Chippenham and Frome CSU TIA Phase 1 – Off-peak Optimum option – Chippenham and Frome CSU TIA Phase 2 – Peak “Low risk” births

Optimum option – Chippenham and Frome

CSU TIA Phase 2 – Off-peak

“Low risk” births

Optimum option – Trowbridge and Paulton

Bath University Optimum option – Chippenham and Frome Catchment areas Optimum option – Chippenham and Frome

Least optimum – Trowbridge and Paulton Vulnerability & accessibility To be assessed as part of the Integrated Impact

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Travel Impact Assessment Summary conclusions Assessment

Future demand modelling The proposals for change will improve utilisation in the remaining two FMUs, support the reduction of low risk women choosing the Obstetric Unit by creating AMU capacity, and increase the capacity at the Obstetric Units to respond to the increase in the number of high risk pregnancies.

The proposal will also ensure population growth and repatriation of military personnel can be accommodated within the service.

Conclusion and recommendations

A number of travel impact assessments have been undertaken to analyse the potential impact of our proposed changes on the travel times of low risk women accessing maternity services for their birth pathway.

The travel impact analysis demonstrates that there is no significant impact on travel times for low risk women from reducing from four to two FMUs.

The analysis shows that with the proposed model of two FMUs, travel times for low risk women remain significantly better than for high risk women who, through clinical necessity, have to travel to one of the three obstetric units.

The optimum configuration of two FMUs is Chippenham and Frome in three out of the four travel impact analyses, with the exception of TIA phase 2 when assessing off peak travel times, where there is a very small variation which has Trowbridge and Paulton as the slightly more optimum configuration, with Chippenham and Frome second.

There are a number of additional factors that have been considered as part of these recommendations. These include:

• Environmental • Geography • Choice • Financial

A summary of considerations is set out in the table below:

Factor Consideration Environment (buildings/facilities)

The environment in Frome and Chippenham FMUs is in a better condition than that of Paulton and Trowbridge, therefore associated costs to improve the environment in Chippenham and Frome will be lower.

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Geography

With the proposed introduction of an AMU at the RUH in Bath, retaining Frome FMU to the south of the catchment area provides a broader spread across this area and women from Paulton will be able to access the AMU or travel to Frome FMU

Choice

The number of women choosing Paulton is lower than that of Frome therefore, whilst the travelling impact is very similar between scenario 3.3 and 3.4, patterns of choice support scenario 3.4 as the preferred option

Financial

There are plans to relocate the current maternity services in Trowbridge to a new build incorporating other services. Additional costs would be incurred to re-provide birth rooms in this new build whilst birth rooms are already located in the Chippenham FMU

Based on the outputs of the TIA and our case for change, our recommendation is that optimum location for the two remaining FMUs is Chippenham and Frome.

Quality Impact Assessment

The Quality Impact Assessment has been completed as part of the scoping and development work, and was submitted to Wiltshire CCG’s Clinical Advisory Group. It is attached as a separate document to this IIA, and contains mitigating actions as well as the measures of quality required.

Recommendations

From the findings accumulated so far the recommendations are:

• To agree areas of focus for any further pre-consultation engagement , in particular perspectives considered from the Travel Impact Assessment, or particular populations

• To continue with targeted and universal engagement throughout the consultation period

• A period of engagement to be carried out with those people or groups of people as evidenced as being effected or impacted, in order to gather further evidence of potential impacts of the proposals

• Identify practical solutions to mitigate against negative impacts/enhance positive impacts

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5.8.3 Quality Impact Assessment

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Appendix 5.9: Bath University report of the analysis of the geographic allocation of maternity services

Analysis of the provision and allocation of maternity services in the RUH catchment area

Final report of the analysis of the geographic allocation of

maternity services

Report authors

Dr Neophytos Stylianou PhD

Marianna Frangeskou MSc

Dr Gunes Erdogan PhD

Prof Christos Vasilakis PhD

School of Management, University of Bath

February 2018

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1. Table of Contents

Executive summary ............................................................................................................................. 109 Background ..................................................................................................................................... 109 Key findings of the location analysis ............................................................................................... 109

1. Location analysis of maternity services .......................................................................................... 111 1.1 Data description ........................................................................................................................ 111 1.2 Descriptive analysis of the deliveries data ................................................................................ 111 1.3 Descriptive analysis of the outpatient data .............................................................................. 113 1.4 Location analysis methodology ................................................................................................. 115

1.4.1 Assumption and limitations ............................................................................................... 116 1.4.2 Scenarios for experimentation .......................................................................................... 116

1.5 Results ....................................................................................................................................... 117 1.5.1 Scenario 1 ........................................................................................................................... 118 1.5.2 Scenario 2 ........................................................................................................................... 119 1.5.3 Scenario 3 ........................................................................................................................... 120 1.5.4 Scenario 4 ........................................................................................................................... 121 1.5.5 Scenario 5 ........................................................................................................................... 123 1.5.6 Scenario 6 ........................................................................................................................... 124 1.5.7 Scenario 7 ........................................................................................................................... 125 1.5.8 Scenario 8 ........................................................................................................................... 126 1.5.9 Scenario 9 ........................................................................................................................... 127 1.5.10 Scenario 10 ....................................................................................................................... 128 1.5.11 Scenario 11 ....................................................................................................................... 129 1.5.12 Scenario 12 ....................................................................................................................... 130 1.5.13 Scenario 13 ....................................................................................................................... 131

1.6 Summary of results ................................................................................................................... 132 Appendix ............................................................................................................................................. 134

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Executive summary

Background

The Royal United Hospitals NHS Foundation Trust (RUH) in 2014 acquired a number of maternity

services within the region for a more integrated approach in their provision. As a result, the

maternity service currently comprises an in-house facility in addition to five maternity centres

(Frome, Trowbridge, Chippenham, Paulton and Shepton Mallet – Antenatal and postnatal activity

only) that offer prenatal, birthing and antenatal services. This rather distinctive service configuration

has resulted in what is called the “Bath model” of delivering maternity services. The Women and

Children’s division at RUH commissioned researchers from the Centre for Healthcare Innovation and

Improvement (CHI2) at the University of Bath School of Management to evaluate the model of

service provision currently in use and to support, through quantitative and geographic analysis,

decisions around the strategic reconfiguration of the service.

Key findings of the location analysis

We used a specialised software tool developed by researchers in the University of Bath to help with

identifying the optimal locations of maternity service facilities. We did so by calculating the

minimum distances travelled between a geographic central point of aggregate demand, as defined

by the Middle Layer Super Output Area (MSOA), to the closest maternity facility (for the quickest

route). Aggregate demand, used as input in the tool, was estimated based on historical data of

demand adjusted for the index of deprivation associated with the relevant MSOA.

Our results showed that in all scenarios in which the total number of facilities was reduced, the total

adjusted travelling distance along the optimal routes was longer. This was in line with expectations

as fewer facilities should lead to longer overall travel distances.

• In the case of having four birthing facilities in total (one acute and three in the community),

existing facility locations seem to be well positioned. In this particular scenario, excluding

the existing facility in Paulton offers the theoretically optimal solution.

• In the case of three birthing facilities (one acute and two in the community), there is a small

difference between existing locations and hypothetically choosing new locations, indicating

that existing facilities are well placed. The theoretical optimal solution in this case is

achieved by excluding Paulton and Trowbridge from the configuration. It is worth

highlighting again that any service configuration with three facilities came off worse in the

computer experiments compared to those with four facilities.

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• In terms of outpatient services, we observed monotonic increases in the results with every

reduction in the number of community facilities (RUH was not considered as an exclusion

candidate). In the case of three community outpatients centres in total, Shepton Mallet and

Paulton were not part of the optimal solution. In a two community centre configuration, the

optimal solution included Chippenham and Frome and in the one community centre

scenario the theoretical solution pointed to Frome.

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1. Location analysis of maternity services

1.1 Data description

Data were received form the Business Intelligence Unit (BIU) of RUH. In order to overcome some

data quality issues, the data were provided for the financial years 2015/16 and 2016/17

(01/04/2015-30/03/2017). Data were included in five different spreadsheets: Bookings, Scans,

Outpatients, Admissions and Deliveries. Scholastic data cleaning was performed on all datasets

before embarking on statistical descriptive analysis and location analysis using advanced

mathematical optimisation methods.

1.2 Descriptive analysis of the deliveries data

During the two financial years of the analysis there were 7,711 deliveries performed by the

maternity services. The vast majority (98.76%) was a delivery of a single baby and 1.24% had

multiple births (twins & triplets). Mean (SD) of mother age at the time they booked the delivery

appointment was 30.1(5.622), ranging between 15 and 49.

Of all deliveries, 1,415 (18.35%) were classified as high risk pregnancies and the remaining 6,296

(81.65%) as low risk. Of those deliveries 99.48% resulted in a live birth, Table 1. Further analysis

using the Fisher’s exact test indicated that there is no statistically significant difference (p = 0.185)

between the outcomes of delivery and the risk classification. It should be noted that the risk

classification of the pregnancy, according to expert guidance, is allocated at the initial stages of the

pregnancy and is not revised during the gestation period.

Table 1: Delivery outcome based on risk of pregnancy Delivery outcome High Risk Low Risk Total Live birth 1,404 (18%) 6,267 (82%) 7,671 Stillbirth 8 (25%) 24 (75%) 32 Neonatal death 1 (50%) 1 (50%) 2 Unknown 2 (33%) 4 (67%) 6

Total 1,415 (18%) 6,296 (82%) 7,711

The majority of deliveries are spontaneous vertexes (62.20%), while medically assisted deliveries

account for 14.65%, closely followed by emergency Caesarean birth (13.98%). 9.54% are elective

Caesarean births and the remaining 0.62% are other methods of deliveries. The various delivery

methods are shown by risk of pregnancy in Table 2. Statistical analysis of the differences between

the risk of the pregnancy indicated a χ2 test of 125.6411 (p value <0.001) indicating statistical

significance in the difference between risk classification and delivery method.

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Table 2: Delivery methods according to pregancny risk Delivery methods High Risk Low Risk Total Spontaneous vertex 793 (17%) 4,003 (83%) 4,796 Elective caesarean 218 (30%) 518 (70%) 736 Emergency caesarean 248 (25%) 753 (75%) 1,001 Medically assisted 144 (13%) 986 (87%) 1,130 Other 12 (25%) 36 (75%) 48

Total 1,415 (18%) 6,296 (82%) 7,711

Gestation week ranged from 19 weeks to 43 weeks with a mean (SD) gestation week of 40 (6.81),

Table 3.

Table 3: Gestation week distribution Gestation week Frequency Percentage (%) ≤36 417 5.39 37 421 5.46 38 941 12.2 39 1607 20.84 40 2450 31.77 41 1483 19.23 42 297 3.85 43 1 0.01 Unknown 94 1.22

Total 7711 100

Approximately 3% of all deliveries were home births. Table 4, indicates that most of high risk

pregnancies are taking place in RUH although many take place in either birthing centres or even

home births. It is clear that RUH delivered most babies and Paulton has the smallest number of

deliveries Chippenham, Frome and Trowbridge have relatively equal number of deliveries.

Table 4: Location of delivery Location High Risk Low Risk Total RUH 1,258 (20%) 4,817 (80%) 6,301 Chippenham BC 34 (9%) 354 (91%) 388 Frome BC 42 (11%) 350 (89%) 392 Paulton BC 12 (6%) 184 (94%) 196 Trowbridge BC 30 (7%) 378 (93%) 408 Home Birth 31 (14%) 195 (86%) 226 Other 8 (31%) 18 (69%) 26

Total 1,415 (18%) 6,296 (82%) 7,711

Of the 7,711 deliveries approximately 5% have been transferred during delivery, Table 5.

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Table 5: Deliveries that have been transferred based on delivery location Delivery Location Transfer Total

No Yes RUH 5802 (95%) 273 (5%) 6087 Chippenham BC 350 (92%) 38 (8%) 380 Frome BC 350 (89%) 42 (11%) 392 Paulton BC 184 (94%) 12 (6%) 196 Trowbridge BC 364 (89%) 44 (11%) 408 RUH Home Births 224 (99%) 2 (1%) 226 Other 24 (92%) 2 (8%) 26

Total 7,298 (95%) 413 (5%) 7,711

1.3 Descriptive analysis of the outpatient data

During the two financial years under investigation there were 213,342 outpatient appointments

managed by the maternity services. The appointments were made by 13,943 unique service users.

The mean (SD) appointment number per service user was 15.30 (10.13) ranging between 1 and 93.

Around 7% of service users had one appointment, 25% had ≤6 appointments and 50% of service

users had ≤16 outpatients appointments. 1.4% of the most frequent service users had 40 or more

appointments during the 2 years of the data, Figure 1.

Figure 1: Distribution of number of appointments per unique service users

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Figure 2 indicates the cumulative frequency distribution of appointments by service users. It can be

clearly seen that service users with 10+ appointments within the two years of the dataset account

for approximately 65% of all appointments booked (as indicated by the vertical red line).

Figure 2: Cumulative frequency distribution of number of appointments by service user

There were 52 different reasons for outpatient appointments. Most appointments were maternity

follow ups (65.55%), followed by home visit follow up appointments (13.16%) and new maternity

appointments (6.40%). Many of the reasons for outpatient appointments (20) had five service users

or fewer each (see Table A1 in the Appendix for detail).

The dataset records the outcome of the appointments. Out of the 213,342 appointments 44.24%

were offered another appointment and 27.46% an appointment would be made at a later date.

3.88% were fully discharged by the consultant’s care while no outcome was recorded in about 1 in 4

appointments, Table 6.

Table 6: Outcome of outpatient’s appointments Outcome Frequency Percent (%) Another appointment given 94,387 44.24 Appointment to be made at a later date 58,588 27.46 Discharged from consultant's care 8,274 3.88 No Outcome recorded 52,093 24.42

Total 213,342 100

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Outpatient’s appointments took place in all six maternity service locations. Most common was RUH

with almost one in three appointments (30.28%), followed by Chippenham with 24.70%. Smallest

number of appointments was to Shepton Mallet with 3.17%, Table 7.

Table 7: Maternity service location of outpatient's appointments Location Frequency Percent (%) RUH 64,595 30.28 Chippenham BC 52,686 24.70 Frome BC 22,561 10.58 Paulton BC 20,326 9.53 Trowbridge BC 46,357 21.73 Shepton Mallet 6,764 3.17 Other 53 0.02

Total 213,342 100

1.4 Location analysis methodology

The objectives, parameters and scenarios of the location analysis were discussed between the

modelling team and the stakeholders. As part of this discussion, we articulated 12 scenarios to form

the basis of the location analysis.

The analysis was conducted using software developed by University of Bath researchers based on

sophisticated mathematical optimisation techniques.4 The location of a service user was determined

by the Middle layer Super Output Areas (MSOAs)5 their postcode is located in. The latter information

was not provided to the research team due to data confidentiality reasons, and as such MSOA was

the finer level of geographical detail our analysis could be performed at.

The objective of the optimisation algorithm, which was calculated for each scenario, is to minimise

the sum of the distances from each MSOA to the closest facility, weighted by the demand of the

MSOA as well as the deprivation index associated with the MSOA. This objective function aims to

find solutions in which the facilities are closer to the MSOAs with higher populations and higher

deprivation indices.

4 Güneş Erdoğan, An open source Spreadsheet Solver for Vehicle Routing Problems, Computers & Operations Research, Volume 84, August 2017, Pages 62-72, ISSN 0305-0548, http://dx.doi.org/10.1016/j.cor.2017.02.022

5 MSOAs are an aggregate of output areas with similar characteristics. http://webarchive.nationalarchives.gov.uk/20160106001702/http://www.ons.gov.uk/ons/guide-method/geography/beginner-s-guide/census/super-output-areas--soas-/index.html

http://webarchive.nationalarchives.gov.uk/20160106001702/http:/www.ons.gov.uk/ons/guide-method/geography/beginner-s-guide/census/super-output-areas--soas-/index.html

http://webarchive.nationalarchives.gov.uk/20160106001702/http:/www.ons.gov.uk/ons/guide-method/geography/beginner-s-guide/census/super-output-areas--soas-/index.html

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1.4.1 Assumption and limitations

As is always the case in mathematical analysis, we had to make a number of simplifications and

assumptions as follows:

1. In all of the scenarios explored, RUH was the only service which is to be retained at its

original location and was not to be removed from the solution.

2. MSOAs were used to calculate the Index of Multiple Deprivation (IMD)6 for each location.

3. All the calculations were performed based on the population-weighted centroids of the

MSOA as provided by the Office of National Statistics (ONS)7.

4. The optimisation of location was performed on the distance of the shortest driving route (in

other words, the distance of the quickest route).

5. Calculations do not include any capacity considerations associated with each facility, only

demand for services.

6. The results are mathematically “optimal” but not so in a practical sense. For example, each

solution assumes that service user will be referred and indeed attend the facility that is

optimally allocated to them.

1.4.2 Scenarios for experimentation

The scenarios agreed to be explored are shown on Table 8.

Table 8: Agreed scenarios for investigation Scenario number

Demand type

Scenario description

1 Deliveries All deliveries (low and high risk) and as is locations for all existing facilities

2 Low risk deliveries, all facilities (existing locations) 3 Low risk deliveries, acute unit plus 3 additional community facilities

(existing locations) 4 Low risk deliveries, acute unit plus 2 additional community facilities

(existing locations) 5 Low risk deliveries, acute unit plus 1 additional community facility

(existing locations) 6 Low risk deliveries, acute unit as is and 3 additional community

6 IMD is a measure of relative deprivation for small areas (Lower Super Output Areas). It is a combined measure of deprivation based on a total of 37 separate indicators that have been grouped into seven domains, each of which reflects a different aspect of deprivation experienced by individuals living in an area https://www.gov.uk/government/statistics/english-indices-of-deprivation-2015. IMD was calculated for MSOAS by Knowledge and Intelligence Service of Public Health England (PHE) and it is available via the Epidemiology and Surveillance function through [email protected]

7http://webarchive.nationalarchives.gov.uk/20160110200251/http://www.ons.gov.uk/ons/guide-method/geography/products/census/spatial/centroids/index.html

https://www.gov.uk/government/statistics/english-indices-of-deprivation-2015

mailto:[email protected]

mailto:[email protected]

http://webarchive.nationalarchives.gov.uk/20160110200251/http:/www.ons.gov.uk/ons/guide-method/geography/products/census/spatial/centroids/index.html

http://webarchive.nationalarchives.gov.uk/20160110200251/http:/www.ons.gov.uk/ons/guide-method/geography/products/census/spatial/centroids/index.html

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facilities anywhere 7 Low risk deliveries, acute unit as is and 2 additional community

facilities anywhere 8 Low risk deliveries, acute unit as is plus 1 additional community

facility anywhere 9 Low risk deliveries, acute unit as is plus 1 additional facility in Bath

10 Outpatients As is provision 11 Acute unit plus 3 community facilities (existing locations) 12 Acute unit plus 2 community facilities (existing locations) 13 Acute unit plus 1 community facilities (existing locations)

1.5 Results

We present the results of the location analysis by each scenario.

The value of the objective function was calculated for each scenario. This function is the sum of the

product of the driving duration of the fastest path from the centroid of each MSOA to the closest

birthing centre, the population of the MSOA, and the deprivation index of the MSOA. There are no

units associated to this metric and for the purposes of this analysis a smaller value implies a better

result. The optimal solution was the one with the smallest increase in the objective function.

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1.5.1 Scenario 1

Scenario 1, depicted in Figure 3, reflects the current location of birthing centres and which of these

existing centres service users should ideally be referred to, based on fastest path from the

population centre point of their MSOA and the deprivation of the MSOA.

Figure 3: Map of scenario 1 illustrating current locations of facilities in an optimal (hypothetical) scenario of demand assignment

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1.5.2 Scenario 2

Scenario 2 is another scenario reflecting the current situation, but this time we are only looking at a

subset of low risk pregnancies. As Figure 4 depicts, the scenario gives an almost identical map to

scenario 1. This is an expected result, since Table 5 shows that most deliveries happen in RUH

despite the risk classification.

Figure 4: Scenario 2. Demand allocation of low risk births in an optimal (hypothetical) scenario of demand assignment

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1.5.3 Scenario 3

Scenario 3 explores what would be the optimal location of services if one of the birthing centres

were not to be part of the optimal solution, assuming that RUH is constant, and taking into account

deprivation of MSOAs and fastest driving path. The results suggested by the optimisation algorithm

as the optimal are shown in Figure 5 with Paulton not part of the optimal solution. Additional

optimisation results are shown in Table 9, with each birthing facility removed from the solution in

turn. Removing Paulton had the smallest impact in the value of objective function (15%), indicating

why it was the best to be excluded.

Figure 5: Scenario 3. Acute unit plus 3 additional community facilities

Table 9: Effect on objective function value of leaving one community facility out of the model (the bigger the difference from baseline scenario the worse the outcome)

Facility excluded Estimated difference None (Scenario 2) (baseline) Chippenham +26% Trowbridge +22% Paulton +15% Frome +22%

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1.5.4 Scenario 4

Scenario 4 investigates which facilities to keep if two facilities were not part of the optimal solution,

subject to the assumptions listed in scenario 3. Figure 6 depicts the result, with Trowbridge and

Paulton not part of the optimal solution as recommended by the optimisation algorithm and subject

to the limiting assumptions mentioned earlier. Detailed optimisation results are shown in Table 10,

with each combination of birthing facilities removed from the solution in turn. Removing Paulton

and Trowbridge had the smallest impact in the value of objective function (37%), indicating why it

was deemed the best combination to be excluded by the algorithm.

Figure 6: Scenario 4, Low risk births with only two additional community facilities

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Table 10: Effect on objective function value of leaving two community facilities out of the model (the bigger the difference from baseline scenario the worse the outcome)

Facilities excluded Estimated difference None (Scenario 2) Baseline Chippenham, Trowbridge +63% Chippenham, Paulton +41% Chippenham, Frome +48% Trowbridge, Paulton +37% Trowbridge, Frome +65% Paulton, Frome +50%

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1.5.5 Scenario 5

Scenario 5 explores which facility should remain in the optimal solution if only RUH and one other

facility were required. The solution points towards the Trowbridge birthing centre (Figure 7).

Figure 7: Scenario 5, low risk births + one additional community facility

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1.5.6 Scenario 6

Scenario 6 investigates where facilities should be located in a theoretically optimal solution if only

RUH (in its existing location) and three other centres anywhere within the patch were required. The

optimisation algorithm suggests that the best options are actually near the existing centres of

Trowbridge, Chippenham and Paulton. Specifically, facility 2 should be located in 6-97 Malmesbury

Rd, Chippenham SN15, UK, Facility 3 in 28A Woodmarsh, North Bradley, Trowbridge BA14 0SB, UK,

and Facility 4 in 55 Waterloo Rd, Radstock BA3 3ER, UK.

Figure 8: Scenario 6, optimal location with RUH and three additional community facilities anywhere within the region

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1.5.7 Scenario 7

Scenario 7 explores where facilities should be located in a mathematical optimal solution if only RUH

and two other centres anywhere within the region were required. The solution suggest that these

options are actually very near to the existing facilities of Frome and Chippenham. More specifically,

Facility 2 should be located in 1 Field View, Chippenham SN15 2QT, UK and Facility 3 in Iron Mill Ln,

Frome BA11, UK.

Figure 9: Scenario7, optimal location with RUH and two additional community facilities anywhere within the region

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1.5.8 Scenario 8

Scenario 8 is investigating where facilities should be located in an optimal solution if only RUH and

one other facility anywhere within the region were required. The solution suggests the best option is

very close to the existing facility of Trowbridge. More specifically, Facility 2 should be located in 28A

Woodmarsh, North Bradley, Trowbridge BA14 0SB, UK.

Figure 10: Scenario 8, optimal location with RUH and one additional community facility anywhere within the region

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1.5.9 Scenario 9

Scenario 9 investigates where facilities should be located in a theoretical optimal solution with RUH

and one other facility anywhere within Bath only. For this scenario, we restricted the location of the

secondary facility in one of the 26 MSOAs that make up Bath geographically according to ONS. The

mathematical solution suggests that the best option is very near to the existing centre of Paulton

(suggested address is 55 Waterloo Rd, Radstock BA3 3ER, UK).

Figure 11: Scenario 9, optimal solution for RUH with1 birthing centre within Bath

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1.5.10 Scenario 10

Scenario 10, depicted in Figure 12, illustrates the current location of facilities offering outpatient

appointments and where service users should theoretical be referred to in order to minimise their

travel times (fastest path from the population centre point of their MSOA) and the deprivation of

the MSOA.

Figure 12: Scenario 10, current situation of outpatients with (hypothetical) optimal assignment of patients to facilities

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1.5.11 Scenario 11

Scenario 11 investigates which would be the facilities to maintain if three facilities plus RUH were to

be part of the optimal solution, subject to the assumptions listed in scenario 11. Figure 13 depicts

the result, with Chippenham, Trowbridge and Frome being part of the optimal solution as

recommended by the optimisation algorithm and subject to the limiting assumptions mentioned

earlier.

Figure 13: Scenario 11, Outpatients in RUH plus 3 more outpatient facilities

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1.5.12 Scenario 12

Scenario 12 investigates which would be the facilities to keep if three facilities were not part of the

optimal solution, subject to the assumptions listed in scenario 12. Figure 14 depicts the result, with

Trowbridge, Paulton and Shepton Mallet not being part of the optimal solution as recommended by

the optimisation algorithm and subject to the limiting assumptions mentioned earlier.

Figure 14: Scenario 12, Outpatients of RUH plus 2 more outpatient facilities

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1.5.13 Scenario 13

Scenario 13 investigates which would be the facility to keep if four facilities were not part of the

optimal solution, subject to the assumptions listed in scenario 13. Figure 15 depicts the result, with

Frome being part of the optimal solution as recommended by the optimisation algorithm and

subject to the limiting assumptions mentioned earlier.

Figure 15: Scenario 13, Outpatient in RUH and 1 more facility

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1.6 Summary of results

Table 11 shows the objective function values for the scenarios for deliveries and Table 12 shows the

results for the scenarios investigating outpatients, as explained above.

Table 11: Results of optimisation modelling for scenarios investigating delivery facilities (the bigger the difference from baseline scenario the worse the outcome)

Scenario Number of facilities Facilities excluded Estimated

difference Baseline

1 5 N/A N/A N/A 2 5 N/A N/A N/A 3 4 Paulton +15% Scenario 2 4 3 Trowbridge,

Paulton +37% Scenario 2

5 2 Chippenham, Paulton, Frome

+76% Scenario 2

6 4 N/A +9% Scenario 2 7 3 N/A +34% Scenario 2 8 2 N/A +64% Scenario 2 9 2 N/A +105% Scenario 2

Table 12: Results of optimisation modelling for scenarios investigating outpatients’ facilities

Scenario Number of facilities Facilities excluded Estimated

difference Baseline

10 6 N/A

11 4 Paulton, Shepton Mallet

+20% Scenario 10

12 3 Trowbridge, Paulton, Shepton

Mallet

+39% Scenario 10

13 2 Chippenham, Frome, Paulton, Shepton Mallet

+83% Scenario 10

In sum:

1. In every scenario in which the number of facilities was reduced, the objective function value as

estimated by the optimisation algorithm is expected to increase, pointing towards longer travel

distances. This is to be expected as service users, on average, would have to travel farther to

access fewer facilities.

2. In the case of having four birthing facilities in total (Scenario 3, one acute and three in the

community, see Table 65), Paulton was not part of the optimal solution since the effect of

excluding this facility (15%) was not as negative as any of the others. Excluding either Trowbridge

or Frome was associated with an estimated increase of 22% each and Chippenham with 26%.

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3. When considering four birthing facilities in total (as in the point above), existing locations seem to

be well positioned (RUH, Chippenham, Frome and Trowbridge).

4. In the hypothetical scenario of having three facilities in total (Scenario 4, one acute and two

elsewhere), excluding Trowbridge and Paulton from the optimal solution is preferable to any

other combination. This is because the pair was associated with the smallest estimated increase

in the results (37%), with next closest combination being Chippenham and Paulton (41%).

5. In the case of three birthing facilities in total (as in the point above), there is a difference, albeit a

small one, between existing locations and choosing entirely new hypothetical locations for the

two community facilities (Scenarios 4 and 7, 37% compared to 34 %) indicating that existing

facilities are relatively well placed.

6. In terms of outpatient services (Scenarios 10 to 13), we observed monotonic increases in the

results with every reduction in the number of community facilities (RUH was not considered as an

exclusion candidate).

7. In the case of three community outpatients centres in total, Shepton Mallet and Paulton were

not part of the optimal solution. In a two community centre configuration, the optimal solution

included Chippenham and Frome and in the one community centre scenario, the theoretical

solution pointed to Frome.

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Appendix Table A1. Appointment type Number Percentage (%) Maternity F/Up 139842 65.28 Maternity Home Visit F/Up 28076 13.47 Maternity New 13660 6.86 Maternity Consultant F/Up 11633 4.99 Maternity Ward Attender F/up 6346 2.87 Maternity Consultant New 3449 1.68 Maternity Consultant Scan 1891 0.82 Maternity Labour Group 1709 0.79 Maternity Infant Feeding Group 1082 0.50 Ward Attender F/Up 749 0.33 Maternity Home Visit New 565 0.29 Maternity Tongue Tie 501 0.24 Maternity Antenatal F/Up 472 0.22 Maternity Consultant Scan New 438 0.22 Maternity Labour F/Up 403 0.22 Maternity Postnatal F/Up 384 0.20 Research Maternity New 357 0.16 Maternity VBAC Group 351 0.16 Maternity Breastfeeding F/Up 226 0.13 Maternity Tour Of Unit 223 0.11 Maternity Health Promotion 211 0.08 Maternity Combined Mental Health F/Up 180 0.07 Maternity Ward Attender New 175 0.10 Maternity Feeding F/Up 96 0.05 Research New 74 0.03 Maternity Tens/Epidural Group 54 0.03 Maternity Anaesthetic Referral 42 0.02 Maternity Tour Of Unit New 39 0.02 Maternity Tongue Tie New 31 0.02 Maternity Telephone Appointment 17 0.01 Maternity Screening F/Up 15 0.01 Maternity Health Promotion New 12 0.01 Pre Assessment Nurse New 5 0.00 Maternity VBAC New 5 0.00 Research Maternity F/Up 4 0.00 Ward Attender New 2 0.00 Urology F/Up 2 0.00 Dermatology F/Up 2 0.00 Gynaecology MOPS Essure F/Up 2 0.00 Diabetes Pump F/Up 2 0.00 Gen Surg F/Up 2 0.00 Gynaecology MOPS F/Up 2 0.00 Maternity Anaesthetic F/Up 2 0.00

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Gynaecology New 1 0.00 Physiotherapy Obs New 1 0.00 Gynaecology EPAC New 1 0.00 Home IV Therapy New 1 0.00 Gastro IBD Nurse Telephone F/Up 1 0.00 Gynaecology F/Up 1 0.00 Gastro Hepatology New 1 0.00 Physiotherapy Obs F/Up 1 0.00 Maternity Screening New 1 0.00

Total 213342 100

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Appendix 5.10: Bath University report of the analysis of maternity services in the RUH catchment area

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Chapter 6 – Our proposed changes

Appendix 6.1: Vision for BSW LMS Offer to Women

Current - 2017 Offer - 2021 Before Pregnancy

Pre-conceptual care provided to women with diabetes.

Preconception health check will be available to targeted women.

Healthy lifestyle advice provided to all women.

All staff to receive training regarding mental health and promotion of healthy lifestyle for those planning a pregnancy

Antenatal Access to antenatal

services is varied and may be confusing.

Women do not always feel

that there is enough time for them to ask relevant questions and may feel that the discussions are led by the midwife

Continuity of care is

variable across the LMS with some women receiving antenatal continuity but not intrapartum.

Appointments are based

on NICE guidance but there may be duplication between obstetric and midwifery teams.

Ultrasound scanning is

available but availability dependent upon staffing resources at times.

Day assessment facilities

have different opening times and provision of care in different providers.

All women have handheld

notes but one provider out of the three has different notes.

Women do not have

access to their electronic notes. They have access

Single point of access for all pregnant women wishing to access services.

For all maternity service staff to use

an approach that puts the woman at the centre of the care – staff to receive training in making every contact count training.

The majority of women to have the

same team of 4-6 midwives caring for them throughout their pregnancy.

Women are provided with a plan of

appointments when they are booked for antenatal care which follows NICE guidance but fits around work and personal commitments as far as possible. Care to be provided in community hubs wherever possible. Community hubs to incorporate antenatal, postnatal, perinatal infant mental health and breastfeeding support services as a minimum.

Ultrasound scanning to be available

in line with agreed standards. To have consistent day assessment

services across the LMS area. All three providers to have the same

handheld notes. All women to have access to key

elements of their electronic records via an electronic app.

All women to have electronic access

to unbiased information and advice including standardised place of birth information with benefits and

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Current - 2017 Offer - 2021 to general information and advice in their handheld notes.

Women are provided with

a mixture of paper and links to electronic information on recognised sites such Trust websites and NHS websites. There is some variation in information sources

Women have access to

their handheld records where some plans are recorded- mainly by clinicians. Birthplans are recorded in the handheld notes.

Midwives access a variety

of electronic systems to record information – there is not one shared platform for information.

Antenatal screening is

offered to all women- however it may be repeated - dependent upon who is the lead antenatal provider as not all providers have access to view results from other Trusts.

All women to be offered

vaccination in pregnancy. All women are asked at

booking about smoking status.

All women are offered CO

monitoring in line with NICE recommendations

Women at high risk of fetal

growth restriction are offered additional ultrasound surveillance in line with RCOG recommendations

Women receive advice

throughout pregnancy regarding reduced fetal

chances of risks.

All women to be actively involved in creating their care plan and will feel listened to through this process. They will have access to electronic personalised care plans.

A shared platform for health

professionals to access information

Antenatal screening to be offered to all women in line with ANSC recommendations. Maternity staff to be able to access results across LMS.

All women to given information and

to be offered appropriate vaccination in pregnancy

All women are asked at booking

about smoking status. All women are offered CO monitoring

in line with NICE recommendations

Women at high risk of fetal growth restriction are offered additional ultrasound surveillance in line with RCOG recommendations

Women receive advice throughout pregnancy regarding reduced fetal movements and are offered additional fetal surveillance in line with NHSE Saving Babies Lives guidance.

All women to have access to emotional and mental health support.

There will be effective supervisory mechanisms in place to support local midwives to provide safe, quality care.

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Current - 2017 Offer - 2021 movements and what to do if they notice this.

Birth Some women may know the midwife that cares for them in labour

All women do not have the

same access to choice of place of birth with only one of three provider trusts having an alongside midwife led birth unit.

7% of births take place in

an alongside midwife led unit.

Electronic fetal heart

recordings are stored manually in some areas of maternity services.

Fresh eyes review of

intrapartum CTG’s to increase efficacy of interpretation.

Most women to know the midwife who cares for them during their birth

All women to have a choice of place of birth to include home, obstetric unit or midwife led care unit. For each provider Trust to have an option for an alongside midwife led birth unit.

To increase the number of women who have midwife led birth.

All CTGs to be electronically archived.

To have live display of intrapartum CTG’s in centralised area with electronic archiving for review, storage and teaching.

All maternity staff to have standardised training and competency assessment in electronic fetal heart rate (CTG) interpretation.

Neonatal All babies have access to a neonatal unit providing intensive care, high dependency and special care cots. Babies requiring surgery or specialist neonatal intensive care are transferred to an appropriate facility antenatally or immediately following birth.

Focus for all babies to

remain with mothers wherever possible. Participation in Atain neonatal workstreams to minimise separation of mother and baby. Transitional care arrangements differ between providers.

Transitional care

arrangements for babies requiring additional care ( e.g. small babies or babies of mothers with diabetes) is variable across the LMS

All babies have access to a neonatal unit providing intensive care, high dependency and special care cots. Babies requiring surgery or specialist neonatal intensive care are transferred to an appropriate facility antenatally or immediately following birth.

Atain criteria for management of babies to reduce chance of separation of mother and baby- All admissions to NICU for term babies to be assessed by multi-professional team to identify any learning.

Transitional care models to be standardised across the LMS.

Newborn physical examination to take place within 72 hours of birth at a place and time convenient to the mother wherever possible.

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Current - 2017 Offer - 2021 provider units

Newborn physical

examination takes place within 72 hours of birth

Postnatal Postnatal care may be

provided by different midwives at times.

Women requiring additional

support may come into contact with a variety of different practitioners from different services.

Women with a negative

experience are able to access birth reflections service.

Breast feeding support is

available from trained staff with specialist infant feeding clinic available at times.

All postnatal care to be provided by same team of 4-6 midwives.

An integrated approach to support for

families and mothers that facilitates effective communication and supports effective relationship building with integrated care practitioners.

All women to have support with emotional health and mental wellbeing.

All women to have access to opportunity to talk about their birth.

Access to additional ongoing PIMH support where required

Dads to feel involved and have access to information that is meaningful for them in an electronic format as well as verbal format.

Breast feeding support to be

available in a timely way in a place that is accessible to women.

Safety Learning identified within Trusts from maternity and other incidents.

Sign up to national

maternity and neonatal safety collaborative in second wave (2018-2019) and third wave (2019-2020).

Some variation in guidelines

and policies across the LMS

Shared learning across the LMS from serious incidents and other incident investigations led by a multi-professional LMS safety sub-group .

Use of national maternity indicators and quality improvement metrics.

Investigations undertaken in conjunction with HSIB where indicated.

Reporting of all relevant stillbirths, neonatal deaths and neonatal brain injuries using the PMRT tool.

Robust investigations for all incidents which are peer reviewed.

All staff to have received training in quality improvement methodology.

Staff to feel confident and skilled to undertake their roles to provide high quality care.

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Current - 2017 Offer - 2021

To align and standardise policies as far as possible across the LMS including triage system.

For staff to be able to access shared guidelines electronically.

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Appendix 6.2 Letter from B&NES CCG re future of Paulton Hospital

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Chapter 7: Governance

Appendix 7.1: terms of reference of the Acute Maternity Services Redesign Steering Group

1. Constitution

The B&NES, Swindon and Wiltshire Maternity Strategy & Liaison Committee (MSLC) hereby resolves to establish a Steering Group to be known as the Acute Maternity Services Redesign Steering Group (the Steering Group). The Steering Group has no executive powers other than those specifically delegated in these terms of reference.

2. Terms of Reference

a. Background

The Local Maternity Services Transformation Plan details the system wide response across the Strategic Transformation Partnership (STP) footprint to the national Better Birth Recommendations and the NHS Five Year Forward View. The Local Maternity System (LMS) covers Bath and North East Somerset, Swindon and Wiltshire (BSW). The plan describes the vision for local maternity services to ensure that “all women have a safe and positive birth and maternity experience, and be prepared to approach parenting with confidence.”

b. Purpose

The Acute Maternity Services Redesign Steering Group is one of the workstreams established to deliver the LMS Transformation Plan (see appendix 1). It is the group that will make recommendations to the relevant approval committees regarding the redesign of services provided by the acute trusts within the LMS.

The Local Maternity Services Transformation Plan builds on the RUH Maternity one system wide transformation programme.

The Steering Group will ensure the project’s effective planning and delivery, and provide assurance to NHS England that its process for service reconfiguration has been adhered to.

c. Objectives • Oversee the process to review maternity services within the BSW LMS, ensuring

that there is documented evidence that it is compliant with the NHS England process for service reconfiguration and can demonstrate that it meets the four tests and bed test for service change;

• Ensure the proposals for service redesign fit with national and LMS strategy for maternity services;

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• Ensure the views of service users, the public and other stakeholders are used to inform the service change;

• Be cognisant of the impact of change at one organisation on other organisations within the LMS and those bordering the LMS;

• Recommend for approval the shortlist of options to take forward to public consultation;

• Recommend for approval the documentation for each stage of the redesign process prior to organisational approval, including the clinical case for change, equality and equity impact assessment/integrated impact assessment, public consultation materials, consultation outcome document, and decision-making business case.

• Oversee the process with the South West Clinical Senate to receive assurance around compliance of test 3 and the bed test in the NHS England process for service reconfiguration.

• Review strategic risks and issues and ensure that they are actively managed.

• Receive regular reports from the workstreams to ensure the programme is delivered to the agreed timeline, and ensure that any risks scored 12 and above are being mitigated or issues are being managed.

3. Membership

The membership will be:

Name Job title Role Jo Baden-Fuller Consultant in Obstetrics and Gynaecology,

SFT Consultant lead

Lucy Baker Acting Director of Acute Commissioning, Wiltshire CCG (Chair)

Programme Director and Wilts commissioning lead

Carmen Chadwick-Cox*

Deputy Director of Programme Management and Transition, Somerset CCG

Link with Somerset maternity service review

Cathy Caple Head of Commercial Projects, RUH Project Manager Fiona Coker Head of Midwifery, SFT Lead midwife Daisy Curling GP, B&NES GP lead Lucy Davies GP, Wiltshire GP lead Debbie Forward* Senior Commissioning Manager,

Preventative Services

People and Communities, Bath and North East Somerset Council (Deputy Chair)

Commissioning lead

Teresa Harding* Divisional Manager, GWH Acute Trust service lead

Lisa Harvey Director of Nursing, B&NES CCG Quality, safety and effectiveness lead

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Name Job title Role Rhiannon Hills Divisional Manager,

Women and Children’s Division, RUH

Acute Trust service lead

Sally Johnson Public health consultant, Wiltshire CCG Public health lead Sarah McLennan* of Communications, Wiltshire CCG Commissioner Comms

and Engagement lead Sarah Merritt* Head of Nursing and Midwifery, RUH Midwifery lead Emma Mooney* Head of Communications, RUH Provider Comms and

Engagement lead Sujata McNab Deputy Director of Finance, Wiltshire CCG Finance lead Sandra Richards LMS Midwife, Wiltshire CCG BSW LMS Midwifery

Project Manager David Walker Consultant in Obstetrics and Gynaecology,

RUH Consultant lead

Trudi Webber MSLC Vice Chair Service user Alison West Associate Director for Quality, Wiltshire

CCG Quality lead

*May send a deputy

a. Quorum

A quorum shall be one half of the members which must include the Chair or Deputy Chair, one commissioner and one member of the RUH.

b. Attendance by Members

Members will be required to attend a minimum of 80% of all meetings and where applicable, are allowed to send a deputy.

c. Attendance by Officers

The Steering Group can co-opt as necessary other Trust staff when discussing areas of the operation that are the responsibility of that member of staff or requiring external guidance or advice.

4. Accountability and Reporting Arrangements

The Steering Group will be accountable to the BSW MSLC (see appendix 1). The outcomes of the meeting will be presented to the BSW MSLC by the Chair, or their nominated deputy, who shall draw to their attention any issues that require disclosure or require executive action.

5. Frequency

Monthly meetings shall be held face to face. However, in order to ensure pace of decision making, conference calls will be scheduled for the alternate fortnights.

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6. Authority

The Steering Group is authorised by the BSW LMS Programme Board to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any request made by the Steering Group.

Figure 4: Acute Maternity Services Review Steering Group reporting structure

Governance

LMS Programme Board (Maternity

Forum)

STP Planned Care Programme Board

STP Executive Board

STP Sponsoring Board

Maternal Health Strategy & Liaison

Committee LHE

Communication & Engagement Working Group

Acute Maternity Services Steering Group

Acute Maternity Services Redesign

Group

Finance Working Group

Safety Sub-group

Local Authority HOSC

Commissioner Boards –

Quality, Safety Assurance and

contract management

Provider Boards

NHSE Specialised

Commissioning Neonatal /

Military

Maternal & Neonatal Health

Collaborative

South West Neonatal Network

NHSE South Regional

Maternity Board

South West Maternity Clinical Network

Maternity Voices

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Appendix 7.2: Project Management Roles

Role Purpose Designated body/person

Sponsoring group

Responsible for defining the direction and ensuring overall alignment of the programme with the strategic direction.

LMS Programme Board

Accountable body

Responsible for determining the scope, shape, plans for and authorisation of service reconfiguration (including decisions on consultation). Responsible for the investment decisions.

Wiltshire CCG Board

LMS Programme Board (maternity forum)

Responsible for defining the acceptable risk profile and thresholds for the programme, ensuring the programme delivers within its agreed boundaries, resolving strategic issues between projects, understanding and managing the impacts of change. Signing off key strategic documents and delivering assurance on the programme.

LMS Programme Board

Senior responsible owner (SRO)

Accountable Officer for the successful delivery of the programme.

Wiltshire CCG Accountable Officer

Programme director

Creating and communicating the vision for the programme, providing clear leadership and direction throughout the life of the programme, securing investment needed, ensuring delivery of a coherent capability, establishing the governance arrangements, ensuring viability of the business case, maintaining communication and alignment with senior managers, ensuring assurance is in place, monitoring key strategic risks, chairing the LMS programme board and Acute Maternity Services Redesign Steering Group. Managing the programme budget

Acting Director of Acute Commissioning

Group Director (SARUM)

Wiltshire CCG (system appointment)

Project manager Day-to-day management of the reconfiguration project. Planning and designing the project and monitoring its progress. Developing and implementing the governance framework, coordinating projects and their interdependencies. Lead for development of the pre consultation business case.

Head of Commercial Projects, RUH

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Role Purpose Designated body/person

Project support officer

Day to day administration of the steering group and workgroups, maintaining up-to-date files, documents and records. Arranging and planning meetings.

Project Support Officer, RUH

Communications and engagement lead

Managing, planning and coordinating consistent and effective communication and engagement with patients, the public, external stakeholder organisations and MPs for the programme, and developing the public consultation plan and materials

Head of Communications, RUH;

Associate Director of Communications, Wiltshire CCG

Clinical lead Plans, coordinates and manages the engagement with clinicians

Head of Nursing and Midwifery, RUH

Finance lead Develops the LMS financial plan, and the financial impact of the proposed service changes across the LMS

Deputy Chief Finance Officer, Wiltshire CCG

Analytic Support Provide analytical support on activity analysis and travel flow analysis, and integrated impact assessment

South Central West Commissioning Support Unit

Scrutiny bodies Responsible for reviewing and scrutinising the programme, including financial considerations. Responsible for ensuring that the needs and experiences of local people are considered in the development of the programme, including financial considerations.

Health Overview & Scrutiny Committees (HOSCs) / Health & Wellbeing Boards (dependent local on arrangements)

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Appendix 7.3: Letter from B&NES CCG confirming it will discharge its legal responsibility for the service reconfiguration to Wiltshire CCG

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Appendix 7.4: Updates provided to CCG Governing Body meetings (private sessions)

Date Committee Presenter(s) Organisation Presentation/ Meeting Purpose

28/09/2017 Joint Commissioning Council (JCC)

Rhiannon Hills

NHS B&NES / B&NES Council

Presentation Presentation on process to date and next steps

21/12/2017 JCC Debbie Forward

BANES Council Meeting

For information: To share shortlist of options

08/03/18 BANES Board Lucy Baker BANES Council Meeting

High Level briefing on Maternity Redesign Project

22/03/18 Somerset CCG Governance Meeting

27/03/18 Wiltshire CCG Governance Meeting

Wiltshire CCG Meeting

29/03/18 Wiltshire Health and Wellbeing Board

Lucy Baker Wiltshire CCG Meeting

Inform Wiltshire Health and Wellbeing Board on maternity redesign.


Lucy Baker

Wiltshire CCG, Somerset CCG

Inform Somerset CCG governing body about Maternity redesign

03/05/18 GWH Executive Committee Lucy Baker Wiltshire CCG,

GWH Meeting

Provide update on maternity transformation and service reconfiguration



Update on Maternity Transformation and Service Reconfiguration


31/05/18 Somerset CCG

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Governance Meeting

28/0618 JCC Debbie Forward BANES CCG Meeting

Update on maternity services redesign


05/07/18 Joint CCG with Wiltshire and Swindon

Debbie Forward

BANES CCG, Wiltshire and Swindon

Meeting


24th July 2018

Wiltshire CCG Governance Meeting

Wiltshire CCG Meeting


26th July 2018

Somerset CCG Governance Meeting

Somerset CCG Meeting


5th August 2018

BANES Health and Care Board

Debbie Forward

BANES Council and CCG

Meeting On Agenda

06/09/18 GWH Executive Committee

Lucy Baker, Sandra Richards

Wiltshire CCG, GWH Meeting On Agenda


On Agenda


Wiltshire CCG Meeting On Agenda

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Appendix 7.5: Letters of support from CCGs and STP Board

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Appendix 7.6: Letter from Somerset CCG confirming support

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Appendix 7.7: Engagement with scrutiny bodies


28/09/2017 Joint Commissioning Council (JCC)

Rhiannon Hills

NHS B&NES / B&NES Council

Presentation Presentation on process to date and next steps

07/11/2017 Wiltshire Health Select Committee

Lucy Baker Wiltshire Council Meeting

Update on Maternity Care Strategy

29/11/2017

BANES Health and Wellbeing Select Committee

Debbie Forward


For information: to share maternity transformation plan with committee

21/12/2017 JCC Debbie Forward


For information: To share shortlist of options


Lucy Baker Wiltshire Council Meeting

Update provided

Agenda No: 7 Maternity Care Strategy - information on Maternity Transformation plan. Link to Wiltshire Council page: http://cms.wiltshire.gov.uk/ieListDocuments.aspx?MId=10889&x=1 Link to webcast: https://wiltshire.public-i.tv/core/portal/webcast_interactive/327028

28/03/18 Wiltshire HOSC full committee

Lucy Baker, Fiona Coker, Sarah Merritt, Sandy Richards

Wiltshire CCG, RUH, SFT Meeting

Inform Wiltshire HOSC about latest development for Maternity

http://cms.wiltshire.gov.uk/ieListDocuments.aspx?MId=10889&x=1





https://wiltshire.public-i.tv/core/portal/webcast_interactive/327028





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redesign - Section 78 of minutes from 28.03.18

28/03/18 BANES HWB Select Committee

Debbie Forward BANES CCG Meeting

Inform BANES HWB Select Committee on Maternity transformation plan

06/06/18 Somerset HOSC full committee


Inform Somerset HOSC about Maternity redesign

11/07/2018

Wiltshire Health Select Committee full committee

Emma Mooney, Sarah Merritt

RUH Meeting


18/07/28 BANES HWB Select Committee

Debbie Forward BANES CCG Meeting

Provide an update to BANES HWB Select Committee on Maternity Transformation plan



Presentation on approach to consultation

26/09/18 B&NES HWB Select Committee

Debbie Forward

BANES CCG/Council Meeting

On agenda

3/10/18 Somerset HOSC full committee



6/11/18 Swindon HOSC Lucy Baker Wiltshire CCG Meeting Presentation on approach to consultation

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8/11/18 B&NES full council

Debbie Forward

BANES CCG/Council Meeting


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Appendix 7.8: Letters of support from HOSCs/Health & Wellbeing Boards

Minutes – Health & Wellbeing Select Committee – 26th September 2018 BSW Maternity Transformation - Consultation approach

Sarah Merritt, Head of Nursing & Midwifery, RUH and Tamsin May, Head of Communications, B&NES CCG introduced this report to the Select Committee.

Sarah Merritt said that the Maternity Services reconfiguration programme is committed to continuing to engage with all relevant stakeholders. She added that early engagement and involvement has aimed to create an understanding of the challenges faced and the need for change, and contributed to the co-creation of the proposal for change.

She explained that Stage 1 Approval was gained in May 2018, an initial Stage 2 meeting took place in July 2018 and that a further meeting would take place in October to gain approval for consultation.

Tamsin May highlighted some of the guiding principles to the Select Committee.

• We will clearly set out what we are proposing, why these changes are needed, and why we are consulting with patients and the public. People must be very clear how their views and feedback will be used/have influence, and what the full consultation process involves.

• We will consult with different groups in ways that are meaningful and appropriate for them including face to face meetings and surveys.

• We will use communications and engagement channels which will provide patients, public and other stakeholders out of area information and opportunity to feedback on the proposal.

• We will make sure that information and events are fully accessible, and are shared widely over a sufficient time period, so that all groups can fully engage in the consultation process.

• We will share stakeholder feedback publicly and explain our final decision(s) with honesty and transparency.

She informed the Select Committee that the consultation and communications for the programme is being led by Wiltshire Clinical Commissioning Group on behalf of the Bath & North East Somerset, Swindon and Wiltshire Local Maternity System. She added that the Wiltshire CCG’s communications team, with the support of the Local Health Economy Communications Working Group (LHECWG), is responsible for the planning and implementation of the consultation plan and approach and will:

• Meet regularly as a local health economy communications and engagement group, and provide briefings and updates to communication colleagues from neighbouring CCG and provider organisations

• Work with Healthwatch and CCG PPE leads to ensure service user voice in discussions and decisions.

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• Ensure consultation responses are thoroughly considered and are included as part of the decision making process.

She stated that materials are to be developed to support the consultation will and will include, but not be limited to:

• Core consultation document • Easy read summary of the consultation document • Frequently asked questions (FAQs) and answers • Posters and leaflets summarising key information and signposting to feedback

channels • Dedicated website • Survey for use online and hard copy.

She said that copies of the consultation document will be distributed to health and community settings and stakeholder groups across the local maternity system area as appropriate. She added that the consultation document will be made available in alternative versions e.g. large print, audio, on request.

She stated that a range of communications channels and methods will be used to target key stakeholders and will include:

• Website: A dedicated website will be created to act as a central hub for information and associated materials will be published on the site along with dates of engagement events.

• News Media: Media will be kept informed via briefings and media releases. Media enquiries will be handled in a timely way. Local newspaper adverts may be considered as a way of providing information about consultation events should local coverage (and poster information) need to be bolstered.

• Social Media: Facebook and Twitter will be used to reinforce and signpost to other channels/information as appropriate and will be monitored for relevant feedback.

• Engagement events: Specific events will be provided during the consultation. • Newsletters: Briefings will be provided for publication in partner and other key

stakeholder newsletters.

She explained that responses will be analysed by an independent organisation – The Bath Centre for Healthcare Innovation and Improvement at the University of Bath, to thoroughly and comprehensively analyse all responses to the consultation and provide a consultation report which will be published on the consultation website. She added that we will make clear how consultation feedback has been used to inform decision making.

She said that an Integrated Impact Assessment has been developed with the objective of ensuring the potential impact of any plans on protected groups has been assessed, and identifies those impacted by the proposed changes and ensure they are supported to have their voice heard.

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She added that the initial Integrated Impact Assessment has informed the development and refinement of the consultation strategy and plan to ensure a targeted approach to communications and engagement activities.

She explained that clinical teams have been involved in shaping the proposal for change throughout the programme and we will continue to build on this and undertake further engagement with staff, particularly those working in our maternity services. She added that staff engagement will be led by the provider organisations and will be overseen by the LHECWG to ensure aligned messaging and awareness amongst staff on how they can provide their feedback.

Councillor Lin Patterson commented that the input from staff during this process is crucial.

Tamsin May agreed and said that staff had been involved in informal engagement for the past two years.

Councillor Robin Moss commented that the proof will be seen when the proposals are launched on November 12th as to whether they are a cost saving exercise or seeking to provide a better clinical experience.

Sarah Merritt informed the Select Committee that the Joint Rapid Scrutiny Event was due to take place on 12th November.

The Select Committee RESOLVED to approve the Communications Strategy and Consultation Plan.

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Draft minutes of the Wiltshire Health Select Committee meeting held on 11 September 2018 at Kennet Room - Wiltshire council offices, County Hall, Trowbridge

71 Maternity Transformation – Communications and Engagement plan Sarah MacLennan, CCG, gave an update on the Maternity Transformation programme noting that there had been a high amount of feedback received on the consultation, including consultation with military families. The communication plan was available in the report included in the agenda as well as the commitments outlined. At the end it was; Resolved To approve the approach to consultation and the communications Strategy.

Somerset Scrutiny for Policies, Adults and Health Committee Summary of Outcomes

Update of Maternity Transformation - BaNES, Swindon and Wiltshire - Agenda Item 7

The Committee received an update on the BaNES Swindon and Wiltshire (BSW) Maternity Transformation Programme in relation to the proposed service reconfiguration. BSW has co-created with women, families, staff and stakeholders a vision for future maternity services. This work includes a review of place of birth choices for women to ensure there is parity in provision for the local population and delivering the nationally mandated Better Birth recommendations. Members were also given an update on the Somerset Local Maternity System (LMS) plan. This included increasing midwife led options so that women in Somerset have more midwife-led choice. Somerset Clinical Commissioning Group were working with BSW to anticipate and understand the impact of any proposed changes in Somerset. There was a growing trend away from home births and birthing centres and it was hoped that more information and promotion to pregnant women and their families could help reverse this. It was agreed that the report on the Somerset Local Maternity System plan would be circulated to members of the committee. The Committee noted the report and update.

Awaiting Swindon minutes

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Appendix 7.9: South West Clinical Senate Panel report

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Chapter 8: Consultation Plans

Appendix 8.1: Transforming Maternity Services

Communications Strategy and Consultation Plan

Introduction:

This Communications Strategy and Consultation Plan has been produced to support the Transforming Maternity Services programme to ensure comprehensive communication and widespread consultation over a period of 14 weeks.

The maternity reconfiguration programme is committed to continuing to engage with all relevant stakeholders and this strategy and plan has been informed by over 15 months of informal engagement activity. A summary of informal engagement, feedback received, key themes and how they have been used to inform the development of the proposal for change can be found in chapter three of the Pre-consultation Business Case and will be published on the consultation website (www.transformingmaternity.org.uk).

Purpose

• Ensure that a structured approach is taken to consultation and engagement activities across the LMS.

• Ensure that information about the consultation is clear, easy to understand and widely available.

• Ensure that people know how they can have their say and influence service change through the consultation process.

• Ensure that information is presented in a consistent and coherent way, with an agreed set of key messages.

• Ensure information is timely and accurate and that channels are in place to capture and respond to questions from key stakeholders.

• Demonstrate and inform stakeholders of the outcome of consultation and the impact their feedback has made.

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Our stakeholders

Strategic Partners

• Bath and North East Somerset, Swindon and Wiltshire STP

• BaNES, Wiltshire, Somerset and Swindon CCGs

• RUH, SFT and GWH Trust Boards

• BaNES, Swindon, Wiltshire and Somerset Healthwatch organisations

• Bath and North East Somerset Health and Wellbeing Select Committee

• Swindon Health, Adult and Children Services Overview and Scrutiny Committee

• Wiltshire Health Overview and Scrutiny Committee

• Somerset Scrutiny for Policies, Adults and Health Committee

• NHS England • NHS Clinical Senate

Closest to the project

• RUH Maternity service leads • GWH Maternity service leads • Salisbury Maternity service leads • Maternity Service Steering Group

Keep informed

• NHS Improvement • South West Ambulance Service

Trust • BaNES, Swindon, Wiltshire and

Somerset Patient Participation Groups

• BaNES, Swindon, Wiltshire and Somerset CCG staff

• RUH, GWH, SFT CQC Relationship Managers

• Neighbouring HOSCs – BNSSG, West Hampshire, Oxford

Proactive two way communication

• Mothers and families – current and future service users • Bath and North East Somerset/Swindon

/Wiltshire/Somerset seldom heard groups, individuals and representatives

• Voluntary/third party/support groups dedicated to mothers/maternity services across BaNES, Wilts, Swindon and Somerset

• Wider public • Local media • RUH, GWH, SFT Maternity service staff • RUH, GWH, SFT Council of Governors • RUH, GWH, SFT staffside (unions) • MPs across BaNES, Swindon, Wiltshire and Somerset • BaNES, Swindon, Wilts and Somerset Health and

Wellbeing Boards • BaNES, Swindon, Wiltshire, Somerset Councillors • Paulton Hospital, Trowbridge Hospital, Chippenham

Hospital and Frome Hospital League of Friends • Bath and North East Somerset Village Agents • Somerset Village Agents • Wiltshire Community Engagement Managers • BaNES, Swindon, Wiltshire and Somerset Children’s

Centres • BaNES, Swindon, Wiltshire and Somerset GPs/practice

managers • BaNES Health Visitors (Virgin Care) • Swindon Bath and North East Somerset Councillors • Wiltshire Health Visitors (Virgin Care) • Somerset Health Visitors

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Key messages

A set of key messages will be developed to support engagement and consultation activities and the development of consultation materials. Key themes for messages are outlined below:

Overall:

• Service users are at the heart of everything we do. We want to ensure we offer the right mix of places where women can give birth, to meet women’s needs whilst remaining safe, equitable and responsive to the choices women are making.

• We have the opportunity to make changes to the mix of places where women can give birth, to do this we want to understand what women and families want, so we can use this to help shape our services for the future.

• If we want to continue to provide a high quality service, delivered by the right mix of staff in an appropriate environment, it is not sustainable to continue as we are and something needs to change.

• We want to work in partnership with staff, mums, families and the communities we serve to design our maternity services for the future.

• Any proposed service changes have been informed by those who use the services, staff needs, national guidance and best practice.

• We are committed to providing a range of places where women can give birth, taking into account personal circumstances and preferences, and will continue to offer women a choice of birth place.

• We want to ensure we can continue to provide high quality care in a safe environment, provided by a professional and skilled workforce.

• We will approach consultation with an open mind, prepared to change in light of feedback we receive through our consultation.

Reaching people and hearing views - our overall approach to consultation and engagement

This section describes the key communication and consultation methods/tools that will be used and sets out our approach to public consultation. It builds on the engagement work undertaken to date.

Communications:

• Develop a clear workforce narrative, supported by a range of materials print and videos • Develop a well-structured, jargon-free public consultation document outlining the various

aspects of the proposal for change. • Develop presentation materials to support structured workforce and public consultation

events. • Face-to-face pre consultation briefings: Maternity teams, MPs, media • Issue written staff, stakeholder and media briefings. • Dedicated public website to hold consultation materials and provide online feedback

options.

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• Hard copy and online consultation document. • Publish FAQs that are updated in real time during the consultation. • Comprehensive and aligned approach to social media to support the consultation

process. • Talking-heads videos of clinicians setting out the story/case for change/key messages

and encouraging feedback to the consultation. • Posters and information cards to promote the consultation process and feedback

opportunities. • Regular media promotion to highlight consultation feedback opportunities. • Posters, media and social media to promote consultation events/information.

Engagement and consultation:

The consultation will begin on 12 November 2018 and end on 24 February 2019, this is a period of 14 weeks to allow for the Christmas holiday season.

• Online survey and hard copy booklet which includes survey and Freepost details • Deliberative workshops with key stakeholder groups, including those identified

through Equality Impact Assessment. • Structured programme of staff consultation. • Independent analysis of consultation feedback and production of an outcome of

consultation report. • Representatives from the three Healthwatch organisations within the LMS will be

invited to review the specification for the University of Bath for conducting the analysis of consultation feedback.

Documents:

A consultation document and questionnaire will be available on the dedicated consultation website (www.transformingmaternity.org.uk), along with supporting material. Copies of the document and questionnaire will be printed and will be available at the public meetings, roadshow and street team events.

The consultation document will also be distributed to targeted groups and locations, to reach people who are most likely to be affected by the proposals including mothers, families and those with an interest in maternity services.

Distribute of hard copies of the document will include, but not limited to, the following locations:

• GP surgeries • Acute hospitals • Sure Start Centres • Community hospitals • Freestanding midwifery units • Alongside midwifery units

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• Pharmacies • Post offices • Libraries • Leisure Centres • Council Offices

Key considerations

Communication and consultation activity will ensure that all audiences are treated equally in terms of access to information and opportunities to provide feedback.

The Maternity Redesign Steering Group will be asked to monitor the effectiveness of our communication and range of consultation opportunities.

The effectiveness of the consultation will ultimately be reflected in the outcome report which will be made publically available.

Working with Support groups/patient networks/seldom heard groups/patient participation groups/community engagement managers/Children’s Centres

Across our Local Maternity System we have an extensive network of support groups and other organisations with an interest in maternity services. We will contact these organisations and individuals to encourage sharing and cascading consultation information and opportunities for providing feedback.

We will also provide tailored engagement for these groups according to their requirement to include:

• Offering up speakers to present at a group meeting • Developing a toolkit so these groups can run their own consultation event

Using existing channels and meetings

Across the LMS we have a wide range of regular meetings and existing communication channels which we can use to support and promote consultation. These include Area Board meetings, Wiltshire community engagement managers, Health and Social Care Forums, GP Forums, League of Friends, Healthwatch meetings, Patient Participation Group newsletters, CCG newsletters, GP newsletters and Trust newsletters,

Timetable, key milestone and action plan

The plan below draws on extensive informal engagement activities that have been undertaken to date and sets out an overview of key dates and activity in the immediate lead up to, during and following consultation. The aim is to have one plan for the consultation that the Local Health Economy Communications Working Group (LHECWG) can work together to deliver, to ensure effective and aligned communications and activities.

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This plan will be refined and updated in the lead up to consultation, subject to approval of the proposals to progress to formal consultation, and will be kept under review throughout.

Local Health Economy Communications Working Group (LHECWG)

Activity/milestone Detail Indicative Timescale

Lead

HOSC engagement (BaNES, Wilts, Swindon and Somerset)

Present findings from informal engagement / outline challenges and describe case for change

Throughout – Sept 18

Wilts/BaNES/ Swindon/ Somerset CCGs

Informal engagement feedback and analysis

Made public Autumn 18 Wilts CCG

Pre-Consultation Business Case (PCBC)

Made public Autumn 18 Wilts CCG

Develop Consultation document

Alongside PCBC

Incorporate findings from seldom heard/protected characteristics engagement

Summer 18 LHECWG

Submit papers for NHS E assurance stage 2 meeting

24th July 18 Wilts CCG

NHS E stage 2 assurance meeting

Five tests and conditions applied/best practice checks

31st July 18

CCG PPE Leads Review and input into Consultation document

Aug 18 LHECWG

CCG Lay rep meeting

Review consultation docs and approach/dates

August – September

LHECWG

HOSC meetings Review and incorporate feedback into consultation document and approach

August-September

LHECWG

Legal review of Consultation Document

September 18 Wilts CCG

Further development of consultation document and materials alongside

Including key facts development, leaflets, posters, flyers, social media assets, banners, fact packs, roadshow board displays,

July – October 18 LHECWG

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PCBC feedback forms Further development of consultation plan

Timetable of events finalised July – October 18 LHECWG

Engagement with families planning for military repatriation

Incorporate feedback into consultation and engagement approach

September LHECWG

Develop talking heads videos to support consultation

Sept – Oct 18 LHECWG

HOSC meetings (BaNES, Wilts, Swindon and Somerset)

Support for approach to consultation and engagement confirm arrangements for scrutiny assurance

Sept 18 Wilts/BaNES/Swindon/Somerset CCGs

NHS E Stage 2 Assurance Follow up Meeting

w/c 1 October

CCG, Trust and STP governing bodies (closed session)

Pre consultation business case and consultation document and plan sign off

Sept – October 18

Engagement with neighbouring HOSCs BNSSG, West Hampshire, Somerset and Oxfordshire

Write to outline plans and approach to consultation, offer to meet if required

Sept- Oct

BaNES CCG Board

Provide updates/additional information as required.

4th Oct 18 BaNES CCG

Swindon Health and Wellbeing Board


4th Oct 18 SCCG

GWH Executive committee


16th Oct GWH

Wiltshire Health and Wellbeing Board


17th Oct 18 Wilts CCG

SCCG Governing Body meeting


25 Oct SCCG

RUH Board of Directors


31st Oct RUH

HOSC engagement

Public HOSC meetings Oct 18 Wilts/BaNES/Swindon/Somerset

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(BaNES, Wilts, Swindon and Somerset)

CCGs

Media and social media plan agreed

Encourage and support engagement, manage responses

October 18 LHECWG

Consultation materials and plan finalised (in line with NHS E review and CCG governing body)

October18 Wilts CCG

Consultation document to print

October/Nov 18 Wilts CCG

Briefing clinicians who have responsibilities for/contact with seldom heard stakeholders

Clinicians can support with identifying and sharing engagement opportunities

October - Nov

Staff engagement Face-to-face briefing sessions ahead of formal consultation. Materials and key messages shared

Early November RUH, SFT and GWH

Pre consultation briefing activity

MPs, media November LHECWG

GP and staff briefings issued in each of the LMS areas

November LHECWG

.

The following dates are subject to change depending on the outcome of the above activities. Additional dates will be added for December/January as required.

Activity/milestone Detail Indicative Timescale Lead

Formal S14Z2 statutory consultation begins 12 November 2018 Rapid HOSC meeting with each of the LMS area HOSCs represented

Outline full proposal for change, share consultation document and materials. Proposal to launch consultation shortly after this meeting

12 November 2018

Wilts CCG

Distribution of Maternity services Wilts CCG

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consultation document

locations and public settings

Consultation website launched

Consultation materials available online

12th November Wilts CCG

Consultation materials / posters distributed

Promoting consultation feedback options and feedback opportunities including event dates/times


Media release issued

Announce consultation start/end date, information sources and opportunities to engage


Social media launch

Announce consultation start/end date, information sources and opportunities to engage


Neighbouring HOSCs – BNSSG, Hampshire, Oxford

Outline engagement opportunities, provide update and offer to attend/present at committee meetings if required


Engagement and/or forums with stakeholders

Mums, families, those with an interest in maternity services, seldom heard groups, wider community,

Materials and key messages shared and opportunities to provide feedback

Wc 12 November and throughout

LHECWG

Targeted face to face engagement and/or forums with strategic/key partners

MPs, GPs, media

Materials and key messages shared

Wc 12 November and throughout

LHECWG

Staff side engagement

Face-to-face briefing session. Materials and key messages shared

Nov 2018 and throughout

RUH, SFT and GWH

Staff engagement Staff briefing sessions held in provider

Nov – Feb 2019 RUH, SFT, GWH

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organisations.

Supported through internal channels e.g. newsletters, existing forums, staff intranet

Engagement with neighbouring HOSCS BNSSG, West Hampshire, Somerset and Oxfordshire

Write to provide consultation update, add offer additional information as required

Nov 2019

Programme of consultation events

Core initial programme which will be kept under review during the consultation period and added to as necessary

From Nov to Feb 2019

LHECWG, CCGs

BaNES Primary Care forum and cluster meetings

TBC Nov 18 BaNES CCG

West GP Forum Event

14th Nov Wilts CCG

B&NES CCG patient engagement group Your Health Your Voice

15th Nov BaNES CCG

SCCG GP Commissioning Forum

21st Nov SCCG

SCCG Governing Body Meeting

21st Nov SCCG

Consultation period ends 24 Feb 2019

Independent analysis of feedback, update the Equalities Impact Assessment in light of consultation feedback, and completion of

Feb - April 19 University of Bath

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consultation outcome report Governing body and HOSC presentation of outcome of consultation report

May – June 2019 Steering Group

Consideration of outcome of consultation report

May – June 2019 CCG and provider governing bodies

CCGs governing body and Trust Board decisions

May- June 2019 CCG and provider governing bodies

Communicate outcome to stakeholders

July 2019 LHECWG

Evaluation

Evaluation will be measured through:

• Level of interest/volume of feedback to the consultation e.g. surveys following face to face opportunities e.g. debates, drop ins, interaction through social media.

• Responses to the consultation – responses should demonstrate that we have provided the right level of information to enable people to contribute to the project.

• Equality and Impact assessment will ensure robust consultation and communication. • Degree of influence achieved – what changes were made and how can that be

evidenced i.e. outcome of the consultation report. • Satisfaction with the consultation process and support for the final decision.

Consultation and feedback

Following a 14 week period of statutory consultation through and independent analysis of the feedback will be undertaken by the University of Bath and a full report, detailing feedback will be produced and presented CCG and provider governing bodies and to Health Overview Scrutiny Committees in Bath and North East Somerset, Swindon, Wiltshire and Somerset. The report will be made available via the CCGs’ and consultation websites and distributed to other partners on request.

The outcome of the consultation report and updated Equalities Impact Assessment will also inform the CCG and Trust governing bodies’ decision making as outlined in Chapter 7.9 of the Pre-Consultation Business Case.