Agenda item

The purpose of the report is to share the details of the improvement plan for maternity care with reference to information requested on behalf of the Community and Wellbeing Scrutiny Committee.

The report explains the external reviews that provide the recommendations and inform some of the improvement actions, governance, and delivery of improvement journey, challenges and next steps.

The Chair welcomed health partners present both in the room and those who had joined the meeting remotely. He began by offering thanks on behalf of the Committee for the work health colleagues continued to do daily, including the entire emergency team and frontline staff. Upon welcoming officers, he invited health colleagues to introduce the item.

Chris Bown (Chief Executive, London North West University Healthcare NHS Trust (LNWUHT)) echoed the thanks offered by the Chair, expressing gratefulness to staff for the care they had provided during the pandemic. He advised that LNWUHT were aware Maternity Services at Northwick Park needed to improve, and expressed that the residents of North West London deserved the very best maternity services, acknowledging that there was some work to do to ensure that happened. He advised the Committee that the Maternity Care Improvement Plan, which had been in place before the CQC inspection, had come in response to a number of individual reports detailed in the agenda paper the Committee had received, and from those reports and the CQC inspection report the plan had been developed. Chris Bown highlighted that the Plan was dynamic, had received input from staff, and there had already been a number of significant improvements made since the beginning of the year.

In continuing the introduction, Lisa Knight (Chief Nurse, LNWUHT) advised that looking back over the past 18 months of maternity care, the monthly review of perinatal mortality death rates of babies had highlighted a rise in perinatal mortality death in July 2020. This was flagged with the ICS and support requested, which the ICS provided straight away in the form of a specialist panel to review all of those cases. That panel consisted of neonatal specialist midwives and professors from other units for an external view of what was happening within the organisation. Lisa Knight advised that at the same time other things started to become apparent, for example the Healthcare Safety Investigation Branch (HSIB), who had been reviewing the same cases, started to raise some themes the unit should look in to with regards to its care. As well as this, Health Education England undertook a review and conducted regular work with junior doctors who had fed back that it was a difficult environment to work in and they had issues raising concerns and not getting the support required. A staff survey was conducted, which flagged many themes as detailed in the report. Lisa Knight advised that all of this information was pulled together to form a picture of the ongoing issues within the unit, and from there the Trust started pulling together the Maternity Improvement Plan, supported by the Integrated Care System (ICS). The Plan had also been presented to the quality summit held by NHS England.

Lisa Knight advised the Committee of the three themes the Maternity Improvement Plan focused on. Workforce culture and leadership focused on how the Trust could improve the environment for staff to work in and how civility could be improved. Women centred individual care focused on communications with patients, such as improving interpretation services for users who did not speak English as a first language, and collecting patient feedback to further understand the community in greater detail and formulate individualised care. The final theme was around safe and effective care which looked at policies, benchmarking and pathways for the induction of labour. The Committee were advised that a new leadership team was in place in the maternity unit until at least March 2022, but the main challenge was 40 midwifery vacancies and 5 consultancy vacancies that they were currently trying to recruit to.

With regard to the support the Trust were receiving from the ICS, Lisa Knight advised that they were receiving significant external support from the ICS who were helping with the local maternity and neonatal system in various ways. The ICS were giving opportunities for shadowing and mentoring of the unit’s staff, and some ICS staff were working on a day by day basis with role modelling. On the ground the ICS were giving feedback on a daily basis including suggestions for improvement and working with junior doctors and the director of medical education. Lisa Knight explained that another main element of the Maternity Improvement Plan was around the organisation development programme, and the Trust were working with an external company on this who looked at the day by day management of the service to determine how the Trust could improve organisation and process. As well as working with the ICS and the external management company, the Trust were working with women and the Maternity Voices Partnership, which was considered best practice. The Partnership was helping the unit to look at all of its plans and giving feedback to make pathways better.

Lesley Watts (Chief Executive, NWL ICS) added that the ICS acknowledged the challenges Northwick Park and London North West had, and that the accountability of the Trust Board, as well as Chris Bown and Lisa Knight, had been appreciated by the ICS. She highlighted that the ICS were determined their oversight and input into the service, together with the Trust, would lead to improvement. She highlighted that there were some very good maternity services in North West London and that expertise should be utilised to ensure that all patients of North West London were provided with equal and good service, which they were determined to do. Pippa Nightingale (Chief Nurse, NWL ICS) echoed the sentiments, highlighting that the role of the ICS was to ensure all patients in North West London had safe maternity services immediately, and to conduct assurance. She added that they were working closely with the CQC and other regulators together with Lisa Knight and the team through two-weekly assurance meetings to ensure there was an external view of the progress being made.

The Chair thanked health colleagues for their introductions and invited the Committee to raise comments and questions, with the following issues raised:

The Committee queried what assurances they could give to those expecting their first child that they would have a positive experience at Northwick Park, who might be scared having read the CQC inspection report. Chris Bown advised that the first assurance was that the Maternity Unit at Northwick Park was safe. He highlighted that, through benchmarking, it was clear that the perinatal mortality rates at Northwick Park were now back to what was expected for a unit of its size and its high risk population, with 70% clinically high risk. He added that consistently over the previous 3 months they were seeing high satisfaction rates from the Friends and Family Test, with 97% positive the previous month which he felt was reassuring. For those who did not speak English as their first language Northwick Park had put further resource into interpreters and the speed in which interpreters were used. Chris Bown reassured the Committee that all clinical pathways had been reviewed, and all recommendations deemed ‘technical’ as opposed to ‘cultural’ had been acted upon. He advised that the next step would be to ensure the culture was conducive. Lisa Knight added that on an individual basis she had families contacting her with worries about coming to the unit, and for those who had been in contact they were doing individual reviews of their care with a senior consultant and senior midwife. She highlighted that they had put a lot of information on the website to try to reassure families firstly, and also the telephone link to the 24 hour triage number.

Members of the Committee discussed the leadership and workforce, and queried whether staff members could easily approach the managers within the organisation if they had problems. They felt that the large turnover of staff gave the impression staff had not been able to engage with the leadership. Chris Bown agreed that it had been an issue and the maternity leadership had now changed, with 3 key positions appointed to the roles of Director of Midwifery, General Manager, and Clinical Graduate Doctor. He agreed that a major concern to him and colleagues was the comments in the report about staff being unwilling or scared to speak up, and the Trust wanted to address that. He believed that it was getting better, and advised that he spoke with midwives and obstetricians regularly who did not hold back their views, but the key was for them to engage with their professional and line management. In addition, the Trust had 12 trained ‘speak up’ guardians, so those who felt anxious about talking to their manager could contact a ‘speak up’ guardian confidentially. Chris Bown advised that the Trust had also held a number of listening events with staff in Maternity, and that he and executive colleagues walked the floor a great deal to listen and encourage staff to raise issues. He felt he had seen an improvement in junior doctors raising issues, with the Health Education England report listing it as very positive feedback, but the cultural change would take time. In terms of whether agency staff were equally engaged in the structure and hierarchy of leadership, Chris Bown advised that many agency staff were long term staff known to the Trust who had worked in the unit for many years and were familiar with the Trust. He advised that the Trust clearly wanted to recruit substantive staff and were in competition with the rest of the country for midwives so wanted it to be a good place to work to attract people to work there.

The Committee queried whether the high turnover of staff was in direct response to the culture of bullying detailed in the report. Chris Bown advised that the reasons people left were multi-faceted and there were a whole range of reasons picked up through exit interviews. For example, some people wanted to work in inner London due to the different weighting of salary, some people moved away, some people had left due to the publicity in the media of the CQC report and some people left because they felt bullied or undervalued. Members asked what assurance there was that the Maternity Improvement Plan would address bullying, highlighting that this had been reported in previous papers before the CQC report was published. Chris Bown advised that it was difficult for him to comment on what had happened before his post in March 2020, but expressed it was clear that whatever was put in place was not sustained. He highlighted that the Trust was undertaking a total quality improvement programme that would continue and not stop at a point that was viewed to be the natural end. He added that the Trust would invest in ensuring staff felt valued and that bullying was tackled face on. Through the Board and ICS, the Trust would continue to performance manage the Improvement Plan way beyond its timeline as a continuous improvement programme. Pippa Nightingale added it was important to learn from the past and there was no point repeating previous interventions. She felt this Improvement Plan was different as it involved working as a system. Lesley Watts agreed that there had been a culture of tolerance and now there needed to be a culture that said the Trust wanted staff to work there and look after women safely, and that would mean staff being comfortable to talk and challenge each other in a good natured way. The role of the ICS on resident’s behalf was to ensure constant surveillance to make it clear everybody was expected to have the same mode and level of behaviour and be kind to each other.

In relation to the accountability of leadership, Chris Bown advised that the accountability rested with himself and the Board of the Trust to ensure they had the right level of managers who were skilled to deliver what was required of them. Regarding the previous leadership, he advised that there were core behaviours exhibited by individuals within that service, and the Trust did not tolerate bullying, racism or discrimination and had taken action against individuals where it had been found to exist very quickly and through the appropriate HR processes. He felt that the new leadership team would be better as there was an effective Improvement Plan in place, the right expertise internally and externally to support, and accountability resting with the Board of LNWUHT. He highlighted that the Board met every 2 weeks with the Chief Medical Officer to be challenged on where they were with the Improvement Plan, and there was also a monthly Maternity Improvement Board meeting held in public which was chaired by Chris Bown. He advised that the Board were very aware of the challenge they faced and all execs and non-execs were fully engaged in the Improvement Plan, and challenged where they felt action was not being taken fast enough.

Lisa Knight confirmed that the new leadership team were involved in pulling together the Maternity Improvement Plan rather than the previous leadership. In terms of the new leadership’s involvement with the organisational development programme that an external management Company had been appointed to support, Chris Bown advised that the reason the new leadership would not undertake that work was that the Company was dealing with decades of poor culture which required a level of expertise way beyond normal line management abilities, with significant professional and expert input needed to address the significant challenges the unit had. He highlighted that the Company was a professional Company involved in organisational development programmes for public and private sector organisations for the past 25 years. They would be working to understand staff concerns, engage on concerns, and work with staff to ensure that as a team they worked cohesively, facilitating small groups of staff to bring about a civil approach to how people interacted and worked as colleagues.

Comments in the report were regarding consultants being disengaged, and the Committee queried what that meant. It was confirmed that some consultants were not participating effectively in the multi-disciplinary team working, and the issue was now addressed. There was now at least one member of the new leadership team present at the multi-disciplinary team meeting at the beginning or end of the day, and consultant engagement was part of the organisational development plan.

The Committee expressed concerns about the level of staffing, having heard comments and anxieties raised, and asked how the voice of the midwife had been taken into consideration. Lisa Knight advised that when the issues with staffing and engagement had first been unravelled, they had sat down with staff at various specific events and asked them to contribute to the Maternity Improvement Plan. Staff recommendations were put into the Improvement Plan and it was continually reviewed. There were twice-weekly staff events, with the dates moving around to allow more staff the opportunity to feed back, which Lisa Knight advised were working well, but she had noticed it was the same group of staff who liked to be engaged. They were now working to reach all groups of staff in the right ways to hear their contributions. Out of those conversations with staff, some of the actions taken in response included task and finish groups, which staff were invited to, such as the interpretation task and finish group. She felt that they had made a step forward in relation to staff engagement.

In relation to the level of staffing, Lisa Knight informed the Committee that the hospital were still delivering 1 to 1 in labour. The Trust had not reduced the number of staff on the labour ward but increased it, however Lisa Knight advised that there was a difference between increasing the staff in the labour ward on a day by day basis and the ability to fill it, with the 40 vacancies being where the challenge lay. She advised that they often had to look across the service and move staff around in order to staff the labour ward, which was done regularly on a risk assessed basis. A review of staffing at Northwick Park had been undertaken by Birth-rate Plus, a national Company who reviewed staffing in maternity units based on number of births and other dependencies such as high risk patients. Birth-rate Plus was of the view that the Trust’s staffing was correct based on its activities. The Trust had ensured there was the budget in order to create the right amount of posts, but had 40 vacancies making it challenging day by day. Bank and agency staff were used to bridge the gap. Chris Bown agreed to share with the Committee the number of midwives in each ward currently.

Continuing to answer questions around staffing, Lisa Knight confirmed that the Director of Midwifery reviewed staffing every day along with the matrons of each ward. Staffing was included on the risk register and if there were any concerns around staffing it was escalated to the Trust Operation Centre, which was GOLD Command level. She reassured the Committee there were tools to assess risk and a great deal of experience managing staff to mitigate risk.

In relation to grading and responsibility, Committee members raised questions around the expectations of midwives at different levels. They had heard accounts that newly qualified Band 6 midwives had been asked to act up into Band 7, which included managing the team, and asked whether they were correct. Lisa Knight advised that the Trust did not ask Band 6 midwives to act up into Band 7, but sometimes a Band 6 midwife may be left in charge of the shift which was viewed by the Trust to be reasonable for their qualification. This would not be asked of a newly qualified Band 6 midwife. In response to whether a member of staff would still be expected to manage a shift if they said they did not have the confidence to do it, Lisa Knight advised that there was a 24 hour on-call senior midwife available at all times that could come in if that situation arose and there was always back up. 

It was highlighted that Maternity Assistants were now in post and the Committee asked for more information on the role. The Committee heard that Maternity Assistants were trained to a different level compared to a Health Care Assistant and qualified through a particular maternity programme to a higher grade. They had some advanced skills and specialities, such as in breast feeding, but were not midwives. Their role in the antenatal clinic was around clinical observations, chaperoning and comforting women.

The Committee queried whether there had been considerations around staff remuneration. Lisa Knight confirmed that the Trust had been reviewing salaries as well as bank rates and incentives, with the Director of Midwifery pulling together a paper on that, but the big challenge was that Northwick Park was outside of the inner London weighting.

In relation to policies, Lisa Knight confirmed that there were around 120 policies and guaranteed they were all up to date and followed a monthly review cycle for checking. There was a big piece of work being conducted on the policies with the ICS which involved benchmarking the policies against other organisations’ policies to ensure they were delivering best practice. In terms of the input ‘speak up’ guardians, the Maternity Voices Partnership, and midwives had into the policies, the Committee were advised that some of the policies would be relevant for their input but others were nationally directed policies that could not be negotiated.

The Committee were advised that a risk assessment document had always been in place, but a recommendation from the Ockenden review was that every unit reviewed their risk assessment document, which the Trust had been doing with the local maternity system. The new assessment document had been implemented in April 2021 and the Trust were now in the process of auditing it as it had been in place for several months. The results of the audit were not finalised yet but they had been working on ensuring comprehensiveness of testing at follow up appointments as part of that process, as well as additional training.

The Committee asked whether the Trust were confident that when midwives spoke on the phone to people in labour they were giving clear instructions and information about when they should attend the hospital. A member disclosed their own experience where a family member had their labour delayed which had caused issues. Lisa Knight advised that a 24 hour mobile telephone line had been introduced the previous year, meaning there was greater access for support on the telephone. In relation to the experiences of members, she advised that the feedback was very helpful as they had not heard that feedback from anyone else. In response to the feedback she would ask the Maternity Voices Partnership to check that people were getting the right advice on that line as it had not yet been audited.

Regarding induction of labour, the Committee noted the delays and asked how it was being dealt with. Lisa Knight advised the Committee that the induction of labour was audited every day. There were still delays, and up to 50% could expect a delay in the labour pathway. Some pathway mapping had been undertaken to see where the main delays were, with the help of the Head of Midwifery from another unit who had recently worked on improving the pathway in their own unit. The work looked at discharges from the labour ward, discharges from the post labour ward, staffing, and the pathways in and out. The delays were now starting to reduce but were not at the levels the Trust would like therefore there was still work to do. Lisa Knight offered to bring an update on induction to a future meeting.

Questions were asked about the percentage of continuity of carer, noting there was a 5 year long term plan to move to 100% continuity of carer. Lisa Knight advised that, as an organisation, the Trust had agreed to concentrate on safety and the delivery of the Improvement Plan so had not been putting continuity of carer forward in the same way they had been doing. The figure put forward the previous month was around 40% and it was agreed this would be checked and shared with the Committee.

The Committee noted that many patients did not speak English as their first language, so there may be challenges in communication. They queried whether the Trust employed staff that spoke the various languages or employed interpreters to assist in communications. Lisa Knight advised that it was a mixture of the two. As the volume of languages patients spoke was vast it was not possible to employ people who spoke all of those multiple languages, so there was always access to 24 hour telephone interpretation where required. If a family needed face to face interpretation that option was available but the majority of the time telephone interpreters were used. Currently, there was a Task and Finish Group looking at interpretation, and they were looking at some new companies with products being piloted in a number of hospitals. They hoped to be one of the next pilots. As well as the telephone interpretation services, all of the Trust’s web based services had a Google translate button. Responding to queries on how well patients knew about the interpretation services and whether GPs were informing patients of the service, Dr MC Patel (NWL CCG) advised that when GPs referred patients their referral form would indicate whether a person needed interpretation or language assistance. If a GP picked up any difficulties with language they would report it to the hospital through the shared care booklets patients took with them.

Continuing to discuss the involvement of GPs, Dr MC Patel encouraged the involvement of GPs in the improvement developments, expressing that it was important to have an ongoing dialogue with the GPs who worked with pregnant people on a day to day basis. He would like to have regular attendance from the Trust at GP forums so that all GPs were aware of the changes being made and the Improvement Plan, and noted that it was in the interest of GPs to work with the Trust to improve the service and care for the Brent community.

Further clarity on the antenatal offer was asked for. Lisa Knight confirmed that the antenatal services ran out of Northwick Park and Central Middlesex Hospital, and a very small service was ran out of Ealing, which gave patients the option to come out of a local hospital.

The Committee asked how the Trust supported people who may not be able to access the website and were digitally excluded. They highlighted that, currently, the website did not have information that directly related to assurance for patients following the CQC report. Chris Bown advised that they needed to look at how they could support people without access to technology and would look into the lack of assurance on the website.

Engagement and involvement of patients and their families was raised, including within a cultural context. The Committee wanted to hear the patient voice about their experiences and suggestions on how things could be improved. Lisa Knight advised that the Maternity Voices Partnership meeting was held every week, made up of people who had given birth. The Partnership was not currently representative of the population therefore a piece of work was being conducted with the Chair of the Partnership to get different people from different backgrounds to come forward. This had also been discussed with Healthwatch. The Trust welcomed suggestions from the Committee around patient and family involvement, and how the Partnership might engage all diverse communities for a more representative Partnership.

The Chair drew the item to a close by thanking colleagues for their responses, and invited health colleagues to summarise the assurances they could give families across Brent during the Maternity Improvement process. Chris Bown gave assurance that the service was safe and was not seeing high levels of perinatal mortality. He advised that the service was making progress with the Improvement Plan and CQC report, and highlighted the majority of people who used the service received a positive experience. Lesley Watts assured patients and the sector that the system was doing the right thing and the ICS was confident that the Trust was taking it seriously.

The Chair invited the Committee to make recommendations. Due to the time constraints during the meeting, the Committee were advised by the Chief Executive to agree any final recommendations via email outside of the Committee meeting.

The recommendations which have been prepared as a result of the discussion at the meeting are as follows:

The committee agreed with CQC inadequate judgement for maternity services and to strengthen the improvement plan would like to recommend the following:

1.    That London North West University Healthcare NHS Trust produce a SMART maternity improvement plan, including key activities, milestones and timescales, and responsible officers, to be published online and made available to members of the Committee.

2.    That London North West University Healthcare NHS Trust provide an annual progress report on the maternity improvement plan, with the first update report to be received at the meeting of 22 February 2022, with London North West University Healthcare NHS Trust requested to appear before the Committee again at that time. The report should include a progress update of the SMART improvement plan, in line with the above recommendation.

3.    That London North West University Healthcare NHS Trust consider service user and other key stakeholder engagement in their maternity services improvement plan, specifically:

·         That the Trust include clear mechanisms for engaging with service users and the Maternity Voices Network. 

·         To consider ways to ensure better representation of service users from diverse cultural and language backgrounds in the Maternity Voices Network.   

·         A greater focus and emphasis on strong mechanisms to capture pregnant people’s experiences, opinions, and suggestions for improving the quality of service and care (e.g. Family and Friends Test data should be used on an ongoing basis to shape the improvement plan).

·         That there is active participation from frontline staff and clinicians in the development of the improvement plan, including attendance at the GP forum to ensure system working.

·         That the improvement plan is published in way that enables those affected by digital exclusion to engage.

4.    That the maternity pathway is reviewed to ensure that it includes signposting to further support if required by service users e.g. domestic abuse services, culturally specific issues, after care.

5.    That the Trust guarantees all patients attending the antenatal clinics are assessed by a qualified midwife and that any breaches of the requirement is reported in the risk register.

6.    That ACAS or the equalities commission is invited to review concerns about discriminatory practices, including looking at midwifery terms and conditions of employment, opportunity for advancement and susceptibility to bullying.

7.    That the right and duty of staff to whistleblow in the interests of patient safety is written into their contract of employment.

8.    That the daily ratio of patients to midwives in the Labour ward is recorded and made available on request.

The Committee made the following information requests to the London North West University Healthcare NHS Trust:

1.    The latest data gathered from the NHS Family and Friends Test for maternity services be made available.

2.    The number of midwives employed by London North West University Healthcare NHS Trust maternity services, and the number of vacancies for midwives. This data should cover the last 10 years and be split between community midwives and hospital based midwives, and include data on the number of births and mothers in the community where post-natal care is provided by Northwick Park Hospital.

3.    Information on telephone interpretation facilities, including community languages available, how well this is utilised, monitored and how many service users are aware of this facility.

4.    The available mechanisms for information to be provided to service users who are unable to or do not use the hospital website. 

5.    To provide the response of Maternity Voices to the query relating to telephone advice and guidance on the appropriate time to attend hospital when in labour.

6.    Details on the bandings and grades of midwives and number of years’ experience, including the progression route within the grading structure and progression details of midwives over the past 4 years.

7.    Further details regarding the community midwifery service, how many midwives are employed in this area and their caseloads.