PAC(4) 15-13 paper 3

 

 

Welsh Government Response to the Report of the National Assembly for Wales Public Accounts Committee Report on Maternity Services in Wales

 

March 2013

 

 

 

Further to the letter of 11 February 2013 enclosing the Public Accounts Committee’s report on Maternity Services in Wales we are encouraged to note that the Committee feels that there has been good progress in addressing the concerns of the previous committee.

 

We are also pleased to report that:

 

 

 

 

 

 

Recommendation 1

We recommend that the Welsh Government makes publicly available the Terms of Reference of the Maternity Services National Delivery Board, including details of how the Board is fulfilling these Terms and its programme of work. We also recommend that the output and recommendations of the Maternity Services Implementation Group and its sub-groups should also be made publicly available.

 

Response: Accept

 

A section of the Chief Nursing Officer’s web page now contains a section specifically for Maternity Services. This will be used to update readers on progress in implementing the Strategic Vision for Maternity Services as well as informing them of new initiatives related to maternity services.

The Terms of Reference of the Maternity Board and its programme of work are available on the site along with the first edition of a quarterly newsletter ‘Maternity News’.  Aimed at Midwives and Users the newsletter provides a brief update on the actions to implement the Strategic Vision.

The recommendations of the Maternity Services Implementation Group and the output from the five sub-groups will be posted on the site in April 2013.

 

Recommendation 2

We recommend that the Welsh Government ensures that there is greater clarity on the implementation of Local Delivery Plans and that a clear timetable for the production of these plans is published.

 

Response: Accept

 

We have received a Local Delivery Plan for the years 2012/2013 and 2013/2014 from every Health Board. These are being scrutinised by officials and will be discussed in the Maternity Board meetings.  The purpose of the Maternity Board is:

 

To hold Health Boards to account for delivery of maternity services in line with the key actions within the Strategic Vision for Maternity Services in Wales by:

 

For example one area of performance which will be monitored is smoking during pregnancy.  More mothers living in Wales smoke throughout pregnancy than in any other area of the UK and a reduction in these high rates has been included as one of the key indicators in the Tobacco Control Action Plan for Wales. To identify a way forward, pilot projects in four Health Board areas have been established to test different models of smoking cessation support for pregnant women. 

 

Maternity Board meetings will take place twice yearly during the spring and autumn in order to address previous performance and forward plan delivery improvement.Dates for Maternity Board meetings for 2013 have been set and agreed with Health Boards,


The Workforce Guidelines pull together the existing standards expected for running safe, sustainable services and these guidelines will need to be considered as Health Boards develop their plans for service re-design.

Where there are cross-border issues, Health Boards will be expected to share their Local Delivery Plans with NHS bodies in England.


 

 

Recommendation 3

We recommend that the Welsh Government, in collaboration with the Informatics Sub-Group, develops and implements a consistent and robust electronic data collection process for maternity services in each Welsh health board in order to remove the need for inefficient manual data collection.

 

Response: Accept

 

All Health Boards now have plans in place to refine and extend the use of current operational maternity systems or to replace them in order to collect consistent and robust electronic data, reducing the burden of ineffective manual data collection.

Members of the Informatics Sub-Group, working with other colleagues from the NHS Wales Informatics Service (NWIS), Public Health Wales and Health Boards have identified a process for extracting data from existing NHS electronic operational systems.  The data will be analysed to produce measures and indicators identified by the Indicators sub group. Based on the results of this work, the Information Directorate within NWIS will progress this work to refine a standardised set of data items.

Health Boards will be asked to report on their progress at the spring Maternity Board meetings and they will be expected to present all required data by July 2013.

 

Recommendation 4

We recommend that the Welsh Government clarifies and publishes its definition of “confident and knowledgeable parents” and ensures that:

 

 

Response: Accept

 

The WG accepts this recommendation and will set in hand the work necessary to achieve its objectives.

 

Because a definition of “confident and knowledgeable parents” reflects subjective understandings it has been decided to engage with stakeholders and users to ascertain their views.

 

An all Wales group of stakeholders, including user chairs of the Maternity Services Liaison Committees at Health Board, met in January 2013 to agree on the best method for collecting user satisfaction in relation to both confident and knowledgeable parents and being treated with dignity and respect.

 

It was agreed that all Health Boards would use the same format for asking these questions before a woman leaves the hospital following birth.

 

Good practice will be shared through the Innovations Board set up by the Minister for Health and Social Services and through twice yearly reports from the Maternity Board.

 

Health Boards will also be expected to make this information available to the public though their local web sites and notice boards.

 

Health Boards will be asked to collate the responses and report to the Maternity Board, the first measure being at the autumn Maternity Board.

 

Example Questions to be used by Health Boards in appendix 1

 

 

Recommendation 5

We recommend that the Welsh Government provides clarification on its expectations of the minimum staffing requirements to ensure safe and sustainable midwifery and obstetrics services and that it provides an explanation as to how data collected from health bodies on their midwifery staffing levels provides sufficient detail to determine whether these expectations are being met.

 

Response: Accept

 

The Royal College of Obstetricians and Gynaecologists recommends that consultant presence should be 40 hours per week on a unit unless the unit has over 5,000 births per annum, in which case it should be 60 hours per week.

 

The Royal College of Midwives recommend the use of Birth Rate Plus to determine midwifery staffing levels. 


Welsh Government do not require day to day numbers of staff working in maternity services as Health Boards are expected to manage sickness and absence. However we are confident that we will receive accurate information on compliance with Birth–Rate Plus requirements and the number of medical staff in post.

Our expectation is that all Health Boards will comply with these standards.  In order to ensure this is maintained they will be required to report on their staffing levels at the twice-yearly Maternity Board meetings.

 

Recommendation 6

We recommend that the Welsh Government works closely with Health Boards to ensure that the use of locums and agency staff is managed efficiently in order that the reliance on using temporary staff to fill long-term gaps in staffing provision is minimised. We also recommend that the Welsh Government work with Health Boards to disaggregate the medical staffing costs associated with maternity services from costs associated with Gynaecology.

 

Response: Accept

 

The Welsh Government works closely with all NHS organisations to monitor and scrutinise spend on locum and agency staff throughout the financial year at Health Board Level.  The Welsh Government has also, through the National Delivery Group, stressed the importance of minimising the use of agency and locum staff, and has shared with other Health Boards details of good practice at Aneurin Bevan Health Board to achieve reductions.  Other Health Boards have been asked to consider taking similar steps in order to achieve further cost reductions.  In addition, the use of electronic roster systems has been promoted to ensure best use of permanently employed staff is made.  Financial support for these systems has been made available through the Welsh Government's Invest to Save scheme.  Further consideration will be given to collecting this information at Maternity Services level as part of the performance information requested for the Board meetings  scheduled for spring and autumn.

 

An apportionment of total medical costs between maternity and gynaecology services is currently undertaken by Health Boards to submit specialty costs in the annual national reference cost returns. Generally, Health Boards will use consultant job plans as the basis for apportioning all medical costs between maternity and gynaecology services. The Welsh Government is committed to improving the accuracy of NHS cost data.  We are working with technical group colleagues to improve allocation of medical costs, including locum costs, between maternity services and gynaecology for future reference cost returns within the 2012/13 reference cost returns.  In line with reference cost timetable these will be completed by October 2013. 

 

 

Recommendation 7

We recommend that the Welsh Government works closely with Health Boards to monitor and regularly review the training needs and competency of all maternity unit staff to ensure that more staff are able to interpret Electronic Foetal Heart Rate Monitoring data.

 

Response: Accept

 

The Chief Nursing Officer has led an all Wales Task and Finish Group in agreeing the most appropriate training package, which will for the first time, include an assessment of competence.

 

All Health Boards will now be expected to introduce this training and assessment package by September 2013.

 

Health Boards will report their progress to the Maternity Board in autumn. They will be expected to keep records of staff training and assessment as well as information on the number of serious incidents related to mis-interpretation of CTGs to ensure that the training and assessment package is improving interpretation.

 

 

Recommendation 8

The Committee endorses the recommendation of the Children and Young People Committee to address the shortage of staff in neonatal units and recommends that the Welsh Government takes action to ensure that Health Boards throughout Wales improve their workforce-planning arrangements for neonatal care. In particular we recommend that it addresses the delivery of neonatal services in north Wales when developing work-force plans.

 

Response: Accept

 

Staffing issues remain a challenge although the latest Neonatal Capacity Review indicates progress. In most areas there has been an improvement in neonatal nurse staffing levels. The gap in nursing shortfall has fallen by around 50% from 82.64 whole time equivalent (wte) in the previous review to 42.027 wte in this review.

 

Health Boards are ultimately responsible for workforce levels within their areas. The Welsh Government will hold LHBs to account on the delivery of neonatal services against standards.

 

The Neonatal Network is making progress to resolve workforce issues as a key priority, as demonstrated in the 2013 Capacity Review. The Neonatal Network is:-

·         Developing a robust neonatal workforce plan (medical, nursing, therapies) for the next 5-10 years

·         Working with LHBs to establish nurse clinical rotation programmes to support competency development

·         Developing multi–professional training, based on an audit of needs across LHBs

·         Implementing the nurse workforce acuity tool.

 

 

Recommendation 9

We recommend that the Welsh Government clarifies and publishes its definition of a “significant reduction” in Caesarean section rates along with a timetable by which it expects such a reduction to be achieved.

 

Response: Accept

 

Current data has been received from the Health Boards on their Caesarean rates (shown in the table below).  Reporting will be completed on a monthly basis from April 2013.

 

Health Board

Caesarean Section Rate

Aneurin Bevan

23.7%

Abertawe Bro Morgannwg

25.7%

Betsi Cadwaladr

25.5%

Cardiff & Vale

20.4%

Cwm Taf

29.2%

Hywel Dda

25.9%

Powys

N/A

 

Welsh Government expects to see a reduction in Caesarean section rates where Health Boards are reporting 25% or above during 2013.  Where rates are 25% or higher Health Boards have provided their plans to reduce rates and these will be discussed at the Maternity Board meetings.

 

Health Boards with rates below 25% will be expected to carry out continuous review and improvements to ensure their rates remain appropriate for their populations.

 

Recommendation 10

We recommend that the Welsh Government establishes a more rigorous system for collecting and reviewing information from Health Boards on their Caesarean section rate performance. We also recommend that more regular and meaningful feedback be provided to assist Health Boards to manage progress in reducing rates where possible. This feedback should reflect challenges posed by NICE guidance on caesarean sections.

 

Response: Accept


As detailed above Welsh Government now expects monthly reports on Caesarean Section Rates from Health Boards with accompanying narrative when rates are reported above 25%.  This will be explored further with all Health Boards at the Maternity Board meetings to identify both good practice and weaknesses.  Following each meeting, Health Boards will receive feedback from the Chief Nursing Officer.

 

Where there has been significant improvement in rates, Health Boards will be asked to share good practice through the Innovations Board set up by the Minister for Health and Social Services as well as through all Wales committees such as Heads of Midwifery Advisory Group Wales and the National Specialist Advisory Group for Women’s Health.

 

All Health Boards use local Dashboards to report their Caesarean Section rates to the Health Board so that continuous improvements can be discussed by the executive team.

 

Recommendation 11

We recommend that the Welsh Government clarifies that the data reported by Health Boards on initial antenatal assessments carried out within the first ten weeks of pregnancy is consistent and robust, and specifically that the data should:

 

Response: Partially Accepted


This performance measure was set to ensure that women have early access to appropriate services so that they can receive information, advice and support as soon as is possible. This includes carrying out an initial assessment, taking blood and the writing of a care plan for the pregnancy.

Whilst it is important women are able to access this early advice and support and plans are made for the pregnancy, Welsh Government do not feel that it needs data on whether it was a midwife or a GP that carried out the assessment.

Members of the Informatics Sub-Group, working with other colleagues from the NHS Wales Informatics Service (NWIS), Public Health Wales and Health Boards have identified a process for extracting data from existing NHS electronic operational systems.  The data will be analysed to produce measures and indicators identified by the Indicators sub group. Based on the results of this work, the Information Directorate within NWIS will progress this work to refine a standardised set of data items.

At the spring Maternity Board meeting, Health Boards will be asked to report the proportion of women whose initial assessment has been carried out by 10 completed weeks of pregnancy.

It will only include completed assessments, carried out by an appropriate professional – GP or midwife.

Health Boards will be expected to present all required data by July 2013.

Health Boards will be asked to report.

 

 

Recommendation 12

We recommend that the Welsh Government provide an update to the Public Accounts Committee by July 2013 on each Health Board’s progress in improving maternity services.

 

Response: Accept

 

Welsh Government will be pleased to provide an update to the Public Accounts Committee by July 2013, following the first round of Maternity Board meetings.

 

 

 

Appendix 1

 

 

Did We Deliver?

 

[Please tick where you feel is most appropriate to you on the scale]

 

  1. Our aim is to prepare you and your partner to begin parenting feeling confident and well supported to care for your baby.

 

Did we manage to do this?

 

 


1                      2                      3                      4                      5

None of the time                                                                       All of the time

 

  1. It is important to us that you are treated with kindness and respect.

 

Did we manage to do this?

 

 


1                      2                      3                      4                      5

None of the time                                                                       All of the time

 

Is there anything else you would like to tell us?