We are the Health and Social Security Scrutiny Panel. It's our role to scrutinise Jersey's government on matters of public importance, policy and legislation which falls within these remits.
The Panel’s review looked to assess the current maternity services and whether they could be improved to help better support and assist women and their families through such a momentous stage in their lives. A vast number of individuals chose to engage with the Panel’s review, which spoke volumes about the desire and need for women to share their experiences.
In order to examine this issue, the Panel agreed that it was important to gather information not only on the current policies and facilities but also the lived experiences of women and their families in relation to the current services.
EVIDENCE CONSIDERED
We put out a survey asking for views on the current maternity services. This survey received 656 responses and you can read the findings in the following link.
We conducted a call for evidence and received numerous submissions from people wishing to share their experience of maternity services in Jersey
We commissioned a local research company called 4Insight to conduct focus groups with women and their partners to find out their experience and views on maternity services in Jersey.
We also commissioned Attain Health Management to conduct an indepth review of the current service in order to help inform our own report.
We questioned the Minister for Health and Social Services at a public hearing about the findings of the focus groups and the submissions
So what did we find out?
From our review we made 48 findings and 28 recommendations. We also identified some key overarching themes in relation to Maternity Services. The following section talks about these overarching themes and what we have recommended in relation to them.
Maternity Facilities
We found that, despite numerous review highlighting the current maternity facilities as inadequate, there has been little progress made in upgrading the facilities.
The Panel is therefore extremely pleased that a commitment has been made to upgrade the facilities imminently, which will significantly improve the physical environment, and that it has been backed by substantial funding. Unfortunately, however, it became apparent that there has been little consultation with women who are recent or future users of the service, or with midwives providing the services, when developing the refurbishment plans. We therefore recommend that all maternity staff are given the opportunity to be involved at some point during the design stages of the refurbishment
We also believe that is vital that the Maternity Voices Partnership are engaged with to ensure that service user’s views are taken into consideration as the project progresses. The upgrade is planned to take place in phases over a two-year period, whilst the Maternity Unit remains fully operational. We are extremely concerned that this timescale is too long and will lead to unnecessary disruption for women, their babies and for staff seeking to provide high quality care. For this reason, the Minister should engage an independent estates expert to assess the options for the upgrade work to the Maternity Unit and provide a more rapid response.
Continuity of Care
The Panel has found that there is an inconsistency in the continuity of care for women within the current maternity services. It was also found that compassion is not always at the centre of the culture surrounding the service. Whilst steps are being taken, there is much more progress to be made.
Whilst we found that there is a clear intent within the maternity team to provide continuity of care, it is evident that there is still room for significant improvement. To help address this matter, we have proposed that a midwife-led model of care is defined, which incorporates, at a minimum, continuity of care in the antenatal and postnatal period, with the ambition of extending this to the intrapartum period. The main objective of this model should be to ensure that care is delivered as close to home as possible, to reduce inconsistency of advice throughout a women’s pregnancy and to increase women’s satisfaction with the service.
Improvements to Leadership and Governance
The Panel has found that significant improvements are required in relation to the leadership and governance of maternity services. Due to a lack of clear goals and indicators for the service, as well as concerns around the current leadership model (which does not create the right fora for the voice of midwives to be heard), a single overarching strategy must be developed.
We found that positive and progressive steps were currently being taken by the maternity services leadership team to address cultural and communication issues within the maternity team and to help ensure that all women receiving care feel listened to, supported and respected. A Local Committee has been established with the objective of developing the basis of a culture and behaviour strategy, which will include organisational values. Furthermore, we were advised that the strategy would provide a framework that supports and promotes regular appraisals, improving communication and enhancing interpersonal relationships within maternity services. Without such a framework we believe it is very difficult to challenge behavioural problems and underpin poor culture and therefore agree it is vital to improving the confidence of women and their families in the care provided.
We have recommended that the Local Committee includes multi professional and across sector representation and that the Culture and Behaviour Strategy is published as an integrated part of the Maternity Services Strategy. In addition, the culture strategy should be a statement of the overarching values of the service and the behaviours that will underpin those values.
Our review identified the need for a coherent Workforce Strategy to underpin the current maternity service and to support the new Maternity Strategy. Such a strategy would be vital for assessing whether the midwifery workforce is adequate to support a new model of midwifery-led care. We also found that the current leadership structure is not appropriate for providing leadership to the work required and for ensuring both a consistent clinical model and robust system of governance in maternity services. Furthermore, under the current leadership model, the voice of midwives is not heard in the right fora. In light of these findings, we have made two recommendations. Firstly, that a Maternity Workforce Strategy is developed which considers future workforce requirements, assesses different roles to support all aspects of maternity care, and explores options for staff rotations with partner organisations. Secondly, that an appropriate leadership team for maternity services is created, including the appointment of a Director of Midwifery and an Associate Medical Director, who is also Lead Obstetrician.
Inconsistency in how women and their partners are involved in discussions about the care they receive
The Panel has found that there is an inconsistency in how women and their partners are involved in discussions about what care is received during pregnancy and after giving birth. Whilst the majority did feel involved in care decisions, concerns exist that these processes are not being delivered uniformly.
Whilst the majority of women that engaged with our review felt involved in the decisions about their care, some reported feeling unsupported with their choices or coerced into agreeing to the type of care received.
Breastfeeding Support
There is evidence to suggest that the current information, support and advice in relation to breastfeeding is inconsistent and, in some cases, women have reported a lack of compassion or respect for the manner in which they wish to feed their child. Clarity is required in relation to how and when this information, support and advice is delivered to expecting mothers.
A significant number of women reported receiving either inadequate breastfeeding support or a lack of compassion and respect about how they wished to feed their baby. We found that it is vital that the promotion of breastfeeding is underpinned by women having ready access to well trained professionals, in both the hospital and home, who provide consistent support and advice. The achievement of Stage One accreditation of the UNICEF Baby Friendly Initiative Programme amongst Health Visitors and, most recently, Maternity Services, is commendable and the identification of five breastfeeding ‘champions’ within both services is a positive step. However, recent staff and resource constraints have meant that breastfeeding champions have been unable to be released to work towards the Baby Friendly Initiative. As a result, it is unclear when Maternity Services will be ready to progress to Stage 2 of the accreditation. We have therefore recommended that breastfeeding champions are given protected time to undertake the work and training necessary to fulfil their role. We also recommend that that the whole maternity system (Midwives, GPs, Health Visitors) demonstrate a commitment to achieving full accreditation (all 3 stages) by Spring 2023.
Perinatal Mental Health
The Panel has found that, whilst improvements are being made, significant work is still required to increase and improve mental health support for women and their families during their engagement with maternity services.
It is widely recognised that mental health problems are often associated with times of stress or change in an individual’s life and that pregnancy and the first year after birth is a time where health professionals play a significant role in promoting mental health. Despite being advised that women were routinely asked about their emotional well-being and mental health at their first contact with primary care or their booking visit with the midwife, 21% of respondents to our survey reported that neither their GP or midwife had enquired about their mood or feelings during pregnancy.
Therefore, the Panel has recommended that every expectant mother is routinely asked about her feelings and mood at every antenatal appointment to ensure that any issues are recognised and acted upon as early as possible. There are undoubtedly positive developments being made in the field of perinatal mental health within maternity services.
During our review we learnt of the approval of a business case for a new perinatal mental health pathway which is intended to improve the referral route for new parents, making it clearer and more consistent. However, progress needs to be made quickly and the impact of the investment needs to be monitored. To ensure that the Panel is kept abreast of progress and the outcome of the new pathway, we have asked to be provided with quarterly updates for assurance that maternity and mental health are working collaboratively and delivering consistent care to women and their partners.
Women and families voices and experiences being heard
There is substantial evidence that women and families should be given the opportunity to have their voice heard in relation to maternity services. The Panel found that whilst work is being done to address this through the Maternity Voices Partnership, further work is required in order to improve this for women and their families.
The establishment of the Maternity Services Partnership (MVP) is a very welcomed development and will be an excellent vehicle for enhanced communication between maternity services and women. The Minister for Health and Social Services should therefore ensure that the MVP reports to the maternity services leadership team on an annual basis to provide feedback from women and their families as to their experiences of the service. The Panel’s own survey demonstrated that women wish to have their say on their experiences of maternity care. An annual service user survey and maternity staff survey would be fundamental in shaping a new maternity strategy and setting a bar for acceptable standards of care.
In line with recommendations that were made in the UK as a result of the 2020 Ockenden Review, we have proposed that an independent senior advocate role is created within maternity services to represent women and their families to ensure their voices are heard and any concerns considered and addressed.
CONCLUSIONS
We would like to thank everyone that contributed to our review, especially those who took part in the survey, the focus groups and our advisers for their in-depth report. We would also like to thank 4insight for managing and delivering the focus groups and the Ministerial Team and Department for Health and Community Services for assisting in this process..