The best start: five-year plan for maternity and neonatal care
A five-year forward plan for the improvement of maternity and neonatal services in Scotland.
Chapter Eight: Wider Implications
This report makes a number of recommendations that will change the way that services are organised. Critically, it makes recommendations for the reorganisation of services and the current workforce within NHS Boards. However, a number of the recommendations will need coordination across NHS Boards.
8.1 Managed Clinical Networks
The three neonatal Managed Clinical Networks are well established in Scotland and have made advances in delivering care at a regional level. However, it has been suggested that the networks need to be more integrated and that there needs to be a greater level of national leadership over clinical and organisational decisions around neonatal care.
In maternity care there is also a need to develop mechanisms to facilitate:
- Cross-border referral and transfer of women and babies.
- Management of women and babies with the most complex care needs at a national level.
- Choice for women, including cross- NHS Board choice.
- Conditions for a flexible workforce with regional support mechanisms developed for smaller units or NHS Boards.
A single Maternity Network Scotland should be created to promote sharing of experience and expertise and to create regional or national protocols, for example to manage the most complex conditions at a national level.
There should be a single Neonatal Managed Clinical Network for Scotland with the new model to ensure integrated working across NHS Board boundaries, including input from service management and clinical staff. The maternity and neonatal networks should come together formally on at least an annual basis to promote integrated services.
8.2 Further research
There are a number of recommendations for research priorities and data collection and analysis that were identified through the course of the Review.
It is recommended that consideration be given to developing research capacity and capability, especially in disciplines where it is underdeveloped, to carry out this research to inform implementation of the new model of care.
A list of potential further research is detailed at Appendix I. In addition, consideration should be given to the establishment of a nationally funded, Scotland-wide, multi-year programme of Maternal and Neonatal Health Service Research, to develop the full potential of the existing research community.
The recommendations from the Review and the process of implementation should be evaluated through monitoring the impact for women, babies, families and staff in terms of clinical outcomes, equity, cost and the experiences and views of all stakeholders.
Consideration should be given to developing research capacity to carry out research to inform implementation of the model of care and to funding of a national programme of maternity and neonatal health service research.
The recommendations and their implementation should be evaluated for impact on outcomes and experiences of women, babies, families and staff, and resources.
8.3 Resource implications
In 2014/15, the Scottish Costs Book  data illustrated that the costs for maternity services in Scotland, amounted to over £300 million, with the vast majority of these costs relating to the provision of hospital-based obstetric, midwifery and neonatal services, with the remaining costs utilised for community midwifery.
In the current resource environment, it is important that a systematic prioritisation of the recommendations is undertaken, which includes a full assessment of the costs and of the potential benefits or savings. This is in line with the process outlined in the paper prepared for this Review which set out a framework and associated actions for consideration of the economic implications of the Review recommendations  , with priority being afforded to those issues with the potential for maximum impact.
Within a programme budgeting environment, the overall resource available to deliver maternity and neonatal services and the current deployment of these resources will require further detailed analysis to ensure a full appreciation of the current cost profile within NHS Boards as this will provide the platform to move towards implementation of the recommendations of this Review.
Implications of the new models of care
It is anticipated that the majority of the recommendations will either be cost neutral or have minor recurring costs associated with them, in addition to an element of transitional costs. It is also recognised that over time, improved outcomes will result in significant cost savings. However, it is also recognised that a number of the recommendations are likely to have more significant implementation costs associated with them. The implementation process will require to consider phasing and prioritisation of the recommendations, both in terms of the resource requirements and the capacity within the service to implement change.
There will be implications for staffing resources associated with a number of these recommendations, particularly in relation to additional training and skills maintenance. In addition, detailed, revised workforce planning processes will need to be undertaken to ensure appropriate staffing is deployed to implement and sustain the new models of care. At present, there are a range of staffing profiles and skill mix within NHS Boards and, thus, a detailed assessment will require to be undertaken in each area to define the precise requirements.
There are a number of recommendations, as outlined below that are likely to incur additional costs, although further detailed work is required as the current degree of variation within NHS Boards impacts on the ability to accurately predict additional costs.
Person-centred care: Many units already have facilities for fathers to stay on maternity wards or for parents to stay near neonatal units. However, these will need to be developed or improved in some areas and may need expansion in the three to five Neonatal Intensive Care units to accommodate increased numbers of babies.
In addition, the review of expenses for families proposed within the Review may have some resource implications once completed.
Continuity of carer: Whilst it is anticipated that this can be delivered with the existing complement of midwives and obstetricians, it envisages a shift of resource from hospital to community.
However, there will be a training requirement for a significant proportion of midwives associated with the shift of care to the community and a caseloading model of care.
In addition, an increased number of support staff may be required to support delivery of antenatal and postnatal care locally. The introduction of early adopters will enable a full assessment of the resource implications and sharing of learning across NHSScotland.
Community hubs: This is in line with the general direction of travel for a number of NHS services, and the model envisages utilising existing facilities as far as is practical. For some NHS Boards the cost of relocating this care from central locations to community hubs may have capital implications associated with creating the physical environment of the hub if suitable local facilities are not available. It will be essential that NHS Boards undertake their own assessment of local need and configuration of hubs to make best use of local resources.
Place of birth: The report emphasises a focus on normal birth, and reducing non-medically indicated intervention. It is recommended that all NHS Boards provide a full range of birth place options for women and a range of pain relief options.
Currently, many NHS Boards already provide this range of choice, but where they are not available, there may be cost implications, It is recognised there will be a transitional cost requirement associated with this significant redesign while enhancing community services at the same time as running traditional services. In the longer term it is anticipated that the new model should require less maternity inpatient beds, as there is a move towards promoting normal processes and reducing avoidable intervention, alongside a shorter postnatal stay for some women.
Postnatal neonatal care: For those NHS Boards not currently operating any form of transitional care arrangements, there will be some initial costs associated with the development of the postnatal neonatal care environment and staff training to develop the appropriate skill mix.
Neonatal care: The new model of neonatal care includes a strengthening of paediatric outreach and allied health professional support for local neonatal units, and a national seven-day neonatal community support service. This represents an increase on current staffing provision, however it is expected to realise preventative benefits in terms of early identification and treatment of conditions. It may, over time, also reduce the length of neonatal inpatient stay in hospital. Treating babies at home or in community hubs will require a shift of resource from hospital to community. Further analysis work will need to be done in this area to quantify the detailed staffing requirements.
Training and development of staff
Throughout the Review, a key feature in a number of areas, has been the importance of having a well-trained and developed workforce, with dedicated time for this important aspect. It is anticipated that, in some areas, this will require to be reviewed in a systematic manner and additional resources will be required to ensure consistent application.
Electronic records - development of an electronic women's maternity record and a single national maternity system will require significant investment across Scotland and is likely to take place over a number of years.
Research and Evaluation - it will be important to evaluate the impact of several of the recommendations. In addition, decisions on future research required will have resource implications.
These potential additional costs require to be balanced against the longer term benefits, and reduced resource requirements, from the provision of a local service with less inpatient care and more community-based care.
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