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A Framework for maternity services in Scotland

Service organisation and provision

This section is about service organisation and provision of care. It outlines the key components of a modern maternity service where care is tailored to the needs of individual women and their families and takes account of equality of access to services in line with the social inclusion agenda.

Local Action

• NHS Boards should develop local maternity strategies that incorporate national policies and take account of cross-boundary provision especially in secondary and tertiary services. Information sharing, networking and consultation between NHS Boards must take place;
• Local Healthcare Co-operatives should realise their potential to address local problems, with local answers, tailoring services according to the needs and wishes of the local community;
• NHS Boards should make sure that local consultation and public involvement takes place when planning maternity services;
• NHS Trusts should make sure that services are provided in local community settings that are acceptable and accessible to women and professionals, with easy access to acute services when, and if, necessary;
• NHS Trusts should make sure that explicit policies and practices are in place to empower women individually as full partners in their care. They should involve women and their families in the planning, monitoring and auditing of service provision;
• NHS Boards must make sure that the report, The Role of Nurses, Midwives and Health Visitors in Public Health and The Nursing and Midwifery Strategy are taken into account in future planning and development of services;
• NHS Trusts must make sure that professionals involved in delivering maternity care are skilled, competent and up to date in their clinical practice;
• NHS Trusts must make sure that realistic local solutions are actively pursued in recruiting and retaining staff in remote and rural areas when planning and developing a sustainable service for the future;
• NHS Boards should have systems in place so that women with special needs, such as physical and learning disabilities and mental health problems, have appropriate access to the full range of maternity care;
• NHS Trusts should make sure that interpreters (preferably female) are available for women from minority ethnic communities;
• NHS Trusts should make sure that the time allocated for clinic appointments meets the needs of individual women allowing time for discussion and educational input;
• NHS Trusts should make sure that adequate and appropriate facilities are available for children in antenatal and postnatal clinics;
• NHS Boards should make sure that Maternity Service Liaison Committees are in place, active and resourced with a focus on best practice initiatives;
• There should be managerial integration across NHS Trusts in NHS Board areas so that:
  • Clear care pathways are developed and implemented throughout the year of pregnancy for women and their families;
  • Maternity services are networked to provide tailored continuing care, eliminating boundaries between Acute and Primary Care sectors and between adjacent NHS Board areas;
  • A comprehensive and seamless maternity and neonatal service is adequately resourced at the point of delivery, whether that is within an Acute or Primary Care setting;
  • midwives and NHS Trust management can demonstrate an explicit commitment to developing midwifery leadership and professional autonomy;
  • every woman has the opportunity to choose an appropriate local lead professional for her maternity care. For most women, this will be a midwife who will involve other professionals as appropriate. If specialist obstetric care is required, the midwife should continue working with the woman in partnership with medical colleagues to provide continuity of care;
  • repective professional roles are clarified to minimise duplicationof care, and provide partnership working and a seamless pattern of quality maternity care;
  • Inequalities of access are reduced by improving accessibility, making sure that services are responsive to individual needs, and interventions are targeted at women with particular health or social needs;
  • midwives and obstetricians contribute to the planning and provision of maternity services at NHS Board level. They should also be involved in Local Heathcare Co-operatives to contribute to maternity service provision at the Primary Care interface;
  • locally implemented guidelines are referenced, evidence-based, dated, signed and regularly reviewed;
  • all service provision includes the priciples of clinical governance and clinical standards, and are regularly and rigorously audited.

Views

If they could just remember that you're human. You know that you're a person. You're not a product. You're a person with feelings and needs. And you deserve respect as well. I mean to make your own decisions. (Lay Focus Group)

They were also really encouraging, like they really cared about you and you weren't just another patient but they would take time to sit and talk to you. (Lay Interview)

I kept emphasising through all my antenatal care that I wanted a female doctor, female. And what happens? I had 4 or 5 men around me. I kept emphasising female doctor, please, female doctor. But that day there was just no female doctor on. (Lay Focus Group)

Local Action

• To provide continuity of care and carer:
  • NHS Trusts should develop team, caseload or alternative models of midwifery care;
  • team and caseload approaches to care should replace the DOMINO model;
  • when developing team, caseload or alternative models of care, NHS Trusts should recognise that the size of the team has a direct impact on the level of continuity of care;
  • the fundamental role of the midwife in delivering continuous care and support to women in all risk categories should be explicit and recognised by all professional colleagues;
  • when they are developing models of care, NHS Trusts must acknowledge the needs of all healthcare professionals, with flexible working hours and family friendly/employee friendly policies in line with the EC Working Time Directive and the European Convention of Human Rights;
  • NHS Trusts, in partnership with Local Education Authorities, should make sure that the specific needs of pregnant schoolgirls are met and that all professionals have the skills to support this vulnerable group;
  • the concept of continuity of care and carer must be the goal for all women, but especially targeted to women who are disadvantaged or who have special needs;
  • all professionals involved in the care of women must communicate, co-operate and share information appropriately;
  • professional collaborative working should minimise the opportunities for contradictory or opinion-based advice and practice;
• General practitioners who choose to provide all, or specific elements, of maternity care to the woman and her family should make sure that they have appropriate continuing professional development in this area;
• NHS Trusts should make sure that women are encouraged to adopt healthy eating patterns and good oral hygiene during pregnancy, contributing to both oral and general health;
• NHS Trusts should consider the role of support workers in maternity care. With appropriate training, appraisal and regulation, they should work under the supervision of a midwife, health visitor or other care professional as part of the maternity care team.

Views

At the GP's antenatal clinic I saw the same midwife every time and she also visited me at home postnatally. This I felt was very important as the midwife got to know me, my family and my circumstances and also know my feelings and fears. I felt it would have been really good to have had that same midwife for the delivery as she would have known me so well, instead of having to get to know a stranger at that time. (Lay Interview)

I prefer it when you've got the same midwife throughout. The delivery I'm not so bothered about because you can't be guaranteed. I mean you don't know when you're going to give birth so you can't be guaranteed you're going to have that midwife. But even if you had the same midwife for after care. (Lay Focus Group)

They've got too many strict policies, they're not seeing us all as individuals. Every pregnancy's different. They're not looking at everyone separately and saying "Oh she's a different person". (Lay Focus Group)

If you are caring for a person on a one-to-one basis you have got holistic care. It's not just that she is pregnant, it's that she is a person behind all that and because you know the family as well you are addressing everything. (Professional Focus Group)

Mum had cancer and my sister and I were caring for her at home. The staff encouraged me to take mum with me when I went for a scan. They changed the room around to let the wheelchair in so that she could see the screen and explained everything to her. Staff sat and talked to me about my feelings about my mum for hours. (Lay Interview)

Change is threatening for everyone, whether it's professional or the lay person, but if you're involved in that change then obviously it's less threatening. (Professional Focus Group)

Local Action

• Guidelines produced by groups such as the Scottish Intercollegiate Guidelines Network and the Scottish Programme for Clinical Effectiveness in Reproductive Health, and evidence from Cochrane reviews that are based on best practice, and represent the gold standard in research, should be implemented and used by professionals involved in delivering maternity care;
• NHS Trusts should make sure that the principles of change management meet the training and education needs of professionals before implementing re-engineered services;
• The Royal Colleges, United Kingdom Central Council, National Board for Nursing, Midwifery and Health Visiting for Scotland and educational establishments must make sure that the education and training that professionals receive in Scotland is of a level to ensure accreditation elsewhere in the world;
• NHS Trusts should make sure that professionals educated and trained elsewhere in the world are registered with the appropriate body and are individually screened to make sure that their practice is of an acceptable standard to allow them to work in the NHS in Scotland;
• NHS Trusts should encourage the clarification of individual professional roles to improve mutual respect and a culture promoting peer review and constructive re-validation of competence and performance;
• NHS Boards must make sure that information is made available about the role of the supervisor of midwives as a support both to midwives and women;
• NHS Trusts must make sure that professionals recognise their ethical role and that they act as advocates for women who are vulnerable during all stages of pregnancy and childbirth, as well as acknowledging the need for medical and midwifery students to gain skills and experience;
• NHS Trusts must provide, as discreetly as possible, a safe and secure environment for mother and baby, together with an effective system of staff identification;
• The Royal Colleges and the National Board for Nursing, Midwifery and Health Visiting for Scotland should address the need for joint training of pre-registration medical, midwifery and nursing students engaged in providing maternity care. NHS Trusts should do the same for post-registration students;
• NHS Boards should develop active links for the planning and provision of services with bodies such as social work services and education;
• NHS Trusts must make sure that women are aware of their entitlement to free prescriptions throughout pregnancy and for one year after the birth of their baby;
• So that mothers are aware of the importance of good oral and dental health, NHS Trusts should encourage a dental examination during pregnancy and make sure that all women know of their entitlement to free dental care throughout pregnancy and for one year after the birth of their baby;
• NHS Trusts must make sure that women are aware of their entitlement to free milk and milk tokens after the birth of their baby.

Views

Change is threatening for everyone, whether it's professional or the lay person, but if you're involved in that change then obviously it's less threatening. (Professional Focus Group)

Local Action

• NHS Trusts should make sure that local guidelines are in place, reflecting national guidance, to support clinical decisions taken when transferring women during pregnancy, childbirth and in the postnatal period;
• NHS Trusts should make sure that clear guidelines and procedures are in place to engage the air and land ambulance service, and that the decision is taken at an appropriate level by an experienced professional. Appendix 7 outlines Scottish ambulance activity for 1999/2000.

If you were to ask the Midwife, the General Practitioner and the Health Visitor what their core purpose was in delivering care to the women, you wouldn't necessarily get them focusing along the same lines, although they think they would be, and that's partly around, I think, fragmented care. We might work with different hospitals each of which have slightly different cultures and ethos, and I think that impacts on the mother. (Professional Focus Group)

Further Work to be undertaken

• NHS Boards should address Regional Planning for Maternity Services, linking with other agencies to provide a holistic model of care for mother and baby;
• The Clinical Effectiveness Programme, the Royal Colleges and the Nursing and Midwifery Practice Development Unit should continue to develop and maintain a national database of evidence based practice relating to maternity services;
• The Chief Scientist's Office should ensure that future research priorities identified for maternity services reflect the multi-disciplinary, multi-professional, cross-agency approach;
• The Royal Colleges, the National Board for Nursing, Midwifery and Health Visiting for Scotland, the Scottish Council for Postgraduate Medical and Dental Education and the Remote and Rural Areas Resource Initiative should consider the appropriate multi-professional, multi-disciplinary skills necessary for practice in remote and rural areas to develop appropriate training packages;
• NHS Boards should develop links to facilitate short-term professional exchanges between urban and rural areas so that the skills of all clinicians are maintained and updated;
• The Universities, the Scottish Council for Postgraduate Medical and Dental Education and the National Board for Nursing, Midwifery and Health Visiting for Scotland should consider the need for undergraduate medical, midwifery and nursing students to experience the challenges of maternity service provision in a remote and rural setting;
• NHS Boards should consider developing a locum bank of suitably skilled professionals to meet the needs of professionals in remote and rural areas requiring clinical updates, annual leave and other eventualities. The Scottish Council for Postgraduate Medical and Dental Education, the National Board for Nursing, Midwifery and Health Visiting for Scotland should consider the provision of educational support for this development;
• NHS Trusts should consider incentives to encourage professionals to work in remote and rural areas;
• NHS Boards in remote and rural areas should give consideration to the special requirement for Continuous Professional Development of all professional groups;
• NHS Trusts and the Scottish Ambulance Service should collaborate to develop criteria for the management of clinical situations requiring a rapid air or land ambulance response.
• The Scottish Ambulance Service should progress its development of 24-hour fixed wing and helicopter air ambulance services to provide a comprehensive emergency maternity support service for women and their babies in remote and rural areas.

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