Agenda item

For the Community and Wellbeing Scrutiny Committee to receive an update on the delivery against the London North West University Hospitals NHS Trust Maternity Improvement Plan, the Maternity Strategy, and on the Trust’s regulatory compliance.

Lisa Knight (Chief Nurse, LNWUHT) introduced the report, which updated the Committee on the progress of the Northwick Park Maternity Improvement Plan. She reminded the Committee that Northwick Park Maternity Services had been inspected by the Care Quality Commissioner (CQC) in March 2021 and graded as inadequate. As a result, London North West University Healthcare NHS Trust (LNWUHT) had attended the Scrutiny Committee in August 2021 to provide assurances and present the Maternity Improvement Plan. The CQC had then made a repeat visit in October 2021 where Northwick Park Maternity Services was upgraded from inadequate to requires improvement, which remained the rating at the time of the meeting as there had been no inspection since then. LNWUHT were very pleased with that rating as an outcome after just 6 months and the CQC had said that from a morale perspective and multi-disciplinary team perspective there had been a ‘sea change’ in the department. The link to that report was included in the agenda pack for the Committee meeting and described what further work was being done to improve, in particular in relation to staffing, training and equipment management.

Lisa Knight advised the Committee that there was now a national programme of inspections for all maternity services in the country which had been ongoing for approximately one year. Northwick Park was expecting another inspection fairly soon as business as usual but were not certain whether they were part of the national programme, having been inspected so close to the announcement. As such, preparations were taking place in order to be ready for inspections. As the service had not been inspected for a while, the report included outcomes from the peer assessments undertaken in August 2022 by 14 individuals against the Shrewsbury and Telford report. These assessments found that LNWUHT had maintained compliance on the majority of measures, which was a good outcome, benchmarked against other London areas. The assessment had found 2 areas of non-compliance. One was regarding consultant ward rounds and there had been compliance with that now since November 2022, and one was around workforce planning, particularly around staffing, and whilst that had improved it did remain a challenge. There was still around a 35% vacancy rate in the middle midwifery layer, but there was a solid pipeline of approximately 20 international midwives coming in to Northwick Park Hospital by December as part of the Capital Midwife Programme.

Northwick Park Hospital was on the National Maternity Programme, who were happy with the engagement from Northwick Park Hospital and were helping the Maternity Unit with clinical pathways, triage, governance processes, and preparing for inspection. The Maternity Services Improvement Plan had been moved to a Strategy, and a new National Maternity Improvement Plan had been published the previous week which Northwick Park Hospital was benchmarking against. It had been found that the themes in the Northwick Park Maternity Improvement Strategy aligned with those in the National Programme so there was confidence that LNWUHT was on the right track.

The Chair thanked Lisa Knight for the introduction and invited comments and questions from those present, with the following issues raised:

Councillor Nerva (Cabinet Member for Public Health & Adult Social Care) highlighted the national news regarding the inequality in care in maternity services and racism within the system. From a local authority perspective, he would expect the local authority and local health service at a borough level to treat that as a priority. The Committee had also seen growing awareness and concern amongst the public regarding the performance and standards of care in maternity services over recent years, with some alarming stories being portrayed at a national news level. Pippa Nightingale advised the Committee that the national news had highlighted some of the failures in maternity services across the country. For example, a woman was 3 times more likely to have a still birth if English was not her first language and she was not white British. The key to addressing that was the publication of The Single Maternity Services Delivery Plan, which LNWUHT very much welcomed. Prior to the publication of the single delivery plan there had been a variety of recommendations from different national bodies, so seeing that all in one place made a difference. There would also be a user-friendly version of that plan that families could access to see the improvements needing to be made in maternity services and how that would be achieved. A big part of the work would involve co-design and how local maternity services worked with women, families and communities to design services. There was a very active user group in Northwick Park Maternity Services helping that happen and LNWUHT were ahead of the game with that.

The Committee asked what presenting officers would say were the key features to determine maternity safety for patients. Pippa Nightingale highlighted effective multi-disciplinary teamwork as the key to safe care because multiple different professions were involved in the gestation and birth of a baby. There was a very detailed maternity safety dashboard which was overseen by the Quality Committee and Trust Board as well as across the acute collaborative where benchmarking across the four trusts took place. LNWUHT favoured well in maternity safety outcomes, and had both a maternity safety champion and non-executive director at Board level. The Committee would like to see a focus on continuity of care, number of investigations and learning from them, and workforce issues in future reports.

In relation to section 3.2 of the report regarding external assurance and actions 3 and 7 being non-compliant, the Committee asked why those 2 areas had not been compliant. Lisa Knight explained that one area of non-compliance had been around consultant ward rounds and ensuring these happened twice a day because prior to the peer assessment they were only being conducted in the morning. From November 2022, Northwick Park Hospital had subsequently implemented ward rounds in the evenings as well so would be compliant with that action if re-assessed. The second area of non-compliance was regarding the website which had subsequently been updated as well. Lisa Knight had not reported Northwick Park Hospital as compliant against workforce planning because there was not enough staff, not because there was no plan. LNWHUT continued to raise staffing as a genuine risk which was unresolved, but the hospital was not unique in that position. There was a national issue with the recruitment of midwives and an announcement the previous day that there would be an increase in the number of training places for midwives nationally. Locally, Northwick Park were already working with local universities who provided midwifery training and were now training more midwives, and a new course had been introduced for nurses who wanted to convert from nursing to midwifery.

Continuing to discuss staffing, the Committee highlighted the vacancy rate for band 6 midwives of 35%, and asked whether there was anything specific to Northwick Park Hospital that might have contributed to that. Lisa Knight advised the Committee that this had been long term, and partly due to putting additional money into that layer and never recruiting into those vacancies. When the original CQC inspection had taken place, there had been quite a high turnover of staff but that had now significantly settled. Pippa Nightingale (CEO, LNWUHT) did not feel there was anything distinguishing Northwick Park Hospital from other places that contributed to the drop-off following the completion of preceptorship years. She felt there was a need to look at the national challenge and general pattern students followed. Most students qualified, stayed in the Trust they trained in to do their preceptorship years there, and then after a few years returned home with that experience. As such, London was an exporter of expert nurses. In addition, the inner and outer London weighting factored significantly into recruitment, where only a few miles difference meant there was inner London weighting, such as at Imperial. Having said that, the turnover rate at Imperial and Chelsea & Westminster compared to LNWUHT was higher. LNWUHT benefited from the mature nurses at Band 7, and so there was a whole cycle of training and experience into and out of London that needed to be understood in order to work out how to fill the gaps. Band 7 had been overrecruited to in order to fill those gaps and nursing roles within maternity were recruited to wherever possible. Councillor Nerva added that local authority leads had identified workforce in its widest sense as the biggest issue for the health service in NWL alongside health inequalities and funding. An Integrated Care Board (ICB) meeting taking place that day had recognised the issue and the Brent Borough-based Partnership had made some very clear proposals to the ICB about what could be achieved.

The Committee asked how maternity services could be improved sustainably and the staff in place be retained. Pippa Nightingale felt that making sustainable improvements would be dependent on the culture at Northwick Park Hospital. Individuals worked where they felt they belonged, and so retaining staff within a team would rely on that. She highlighted that culture could not change overnight, but over the past year the culture at Northwick Park Hospital had changed dramatically, and a whole new senior team had been recruited to within maternity services that were really making a difference. She felt that once there was a healthy, inclusive, multi-disciplinary culture then people chose to stay within that unit, so that’s what they were working towards.

The Committee highlighted that many women put their trust in professionals completely and assumed they would know if something was wrong and may not raise the alarm themselves, particularly if they had a language barrier. They queried whether this was something Northwick Park Hospital experienced with its patients. Pippa Nightingale informed the Committee that this happened both nationally and locally. The most common factor of a stillbirth, which Northwick Park Hospital was trying to get to a point of avoiding, was language barriers. Northwick Park was aware that women with a language barrier quite often did not contact maternity services when they would like them to when they had reduced foetal movements. She highlighted this was not the fault of the patient and attributed this to the service, as those women had not been helped to understand exactly when to respond to a problem and contact the service. However, Lisa Knight was leading a team locally with an improvement programme focused specifically on women with language barriers delaying contacting maternity services. The programme looked at how to improve the information to women so they contacted the service straight away and came in when the service would want them to, in the same way that someone who was white British with English as their first language would understand.

The Committee asked how the digitisation of patient records would assist the families of Brent. They were advised that this was the first time there had been a digital system across the four hospitals of Imperial, Chelsea & Westminster, Hillingdon and Northwick Park. Northwick Park Hospital was not a high-risk unit so a lot of women were referred to Queen Charlotte’s at Imperial and there would now be the ability to share notes across both hospitals for the first time. This would help from a patient safety perspective and the standardisation of notes would help with risk pathways as the original notes could flag where women were vulnerable or where their first language was not English. Pippa Nightingale added that the next part of that digitisation project would be linking it to ‘patient knows best’, the patient portal into their own record which was translatable into the top 5 languages. LNWUHT had also commissioned the ’Mum and Baby’ app which had been designed by midwives and obstetricians in North West London for mothers which was also translatable into the top 5 languages. The app allowed mothers to send questions to their midwives and access other information. Maternity services would also be able to see which women had accessed it.

In relation to community midwives, the Committee heard that there were some vacancies there but a nurse consultant post had been recruited to who specialised in community midwifery. That consultant had been in post for 6 months and was overseeing a remodel of community midwifery. LNWUHT took a lot of women from Queen Charlotte’s or Watford for community care, so the number of births delivered by LNUWHT was not actually representative of the care given in the community which was much more. Another piece of work community midwifery was focused on at the moment was where the best place was for women to have their first visit.

The Committee asked whether there was cause for concern regarding C-Section patients being discharged after 14 hours. They were advised this was not a safety issue and generally most women wanted to be at home within 14 hours, which was a generational culture shift. Women were not forced to leave the unit, but generally preferred to go home as soon as they could.

In drawing the discussion to a close, the Chair asked presenting officers how far away from ‘good’ they felt they were. In responding, Pippa Nightingale highlighted that the CNST standards for maternity had just changed. She did not think maternity services at Northwick Park Hospital were at ‘good’ yet but were much closer to ‘good’ than before. She felt if the service was to be reinspected then it would stay at the same rating whereas some places in the country may drop a rating. In responding, she highlighted that CQC was only one regulator out of money. During the past year the maternity services at Northwick Park Hospital had also been inspected by Health Education England, who had subsequently removed an enforcement notice in place after seeing significant improvement.

The Chair thanked those present for their contributions and drew the item to a close. He invited the Committee to make recommendations, with the following RESOLVED:

i)              To recommend that inequalities in maternity care and racism within the system must be tackled as a priority at both system and place levels.

An information request was raised during the discussion, recorded as follows:

i)              For the Committee to receive details of the complaints to investigations ratio for midwifery services at Northwick Park Hospital.

ii)             For the Committee to receive details on the staffing numbers in Northwick Park Maternity Services broken down by band over the past 5 years.