Maternity and neonatal care - Best Start five-year plan 2017–2024: report

Key Achievements: Supporting the Service Changes and Wider Implications

Key Achievements: Supporting the Service Changes (Recommendations 55 – 72) and Wider Implications (Recommendations 73 – 76)

The final section of the Best Start outlined the twenty-two recommendations for the services which underpin or provide elements of care to women and babies in the maternity and neonatal care system. These recommendations were grouped under the following headings:

1.Transport

2.Remote and rural care

3.Planning and supporting the workforce to deliver

4.Continuous quality improvement

5.Information technology, data and telemedicine

6.Managed clinical networks

7.Further research

Transport

Recommendations 55 – 59 related to risk assessment for in utero transfer, a national system for identifying neonatal cot availability, pathways for declaring neonatal cot availability and processes for managing periods of high activity, and on staff training. It also recommended a detailed review of transport services be undertaken by the neonatal transport service. ScotStar, Scotland’s neonatal transport service, undertakes inter-facility neonatal transfers. It is operated by the Scottish Ambulance Service (SAS).

Action on these recommendations has been led by SAS and by the SPN.

The SPN Transport Group, which was established in 2022 as a national, multi-professional working group, has taken forward a range of activities to implement nationally consistent best practice for the timely, safe and effective transfer of pregnant women and their babies.

Key achievements to date include.

• a directory of ‘first point of contact’ numbers for each obstetric unit, to support the ScotStar In utero Coordination Service to reach the decision-makers more quickly within all units, book ambulances earlier and, in turn, help facilitate safer transfers.
• established improved quarterly reporting of in utero transfers (IUT) at unit, Board and Scotland level.
• a national pathway and guidance for In utero Transfers in Scotland: Consultant Led Unit to Consultant Led Unit, was developed and published in March 2023.
• implementation by Boards of fetal fibronectin testing for the risk assessment of early labour, as recommended by the above IUT pathway. The Network worked with national Procurement at NHS NSS to support Boards with access to the most cost-effective solutions to adopt this test via existing national contracts.
• a national Pathway for the Transfer of Women from Community Maternity Units in an Extreme Obstetric Emergency, was developed, and was published in September 2023.

Transport continues to be a key strategic priority for the SPN, with further work ongoing beyond the end of the Best Start programme in June 2024. In addition to the above completed works, the Transport Group are continuing to take forward work on:

• ‘Once for Scotland’ transfer document ensuring referring and receiving units give and have the same information, with the intention of digitising it via BadgerNet once the form has been successfully piloted. This is being tested and links with SPSP-Perinatal work on a pre-term passport to avoid possible duplication.
• developing guidance to support unplanned Pre-hospital Emergency Maternity and Neonatal Care.
• a pathway for Unplanned/Unscheduled (Intrapartum) Transfers in a remote and rural context.
• data linkage using IUT data and PHS delivery records, to ascertain the pregnancy outcomes following IUTs. This information will assist with further development of effective risk assessment approaches, patient-centred care and efficient use of maternity and neonatal service capacity across Scotland. Information governance approvals for this data linkage are in place and tests reports are underway to address any issues with data quality and to ensure that future reporting is robust.

Other key progress includes:

• The ScotStar neonatal transport service has worked closely with the Scottish neonatal networks and Clevermed to develop systems for coordinating in utero and ex utero perinatal transfers, including cot location.
• This system is based on pathways followed by the ScotStar call coordinators along with information supplied by Scottish neonatal units via the BadgerNet system and the daily conference call. The three pathways published are:
  • Ex utero referral, cot secured
  • Ex utero referral, cot not secured
  • ICS Process for IUT requests.
• SAS convene the daily conference call to collate up-to-date information about cot availability across neonatal units. The call is chaired by the duty transport consultant, and neonatal units provide information which is then shared with the Specialist Services Desk who provide the In Utero Coordination Service.
• SAS has also led on undertaking a further, detailed review of transport services to examine the best model for staffing of the service. Three work streams were developed to deliver this objective.

Remote and Rural

Three key achievements were made via this work stream:

• the agreement to utilise 999 ambulances in emergencies where necessary (this included within the remote and rural pathways).
• the continuation of the Remote and Rural Network to facilitate ongoing collaboration.
• collaborated training sessions for remote and rural areas.

Training and Education

This work stream was clear in terms of scope, recognised the needs of the service and identified how this could be delivered. The training and education recommendations were accepted and are either already implemented or are in the process of being implemented. These include competency frameworks, a Quality Improvement Lead and an Education Lead for the service. Full implementation will provide a framework for continuous learning and growth for employees within the service ultimately having a positive and long-lasting cultural impact.

Workforce

General principles have been agreed.

• a one-team working culture, created to guarantee standardised practice across the service (shared guidance, protocols, processes and equipment).
• central co-ordination of transfers, to ensure equity across Scotland as well as the most efficient and effective use of resources.
• a clear staffing structure, with defined and consistent roles.
• all employees work the same shift pattern on clinical sessions.
• collaboration with NNUs is essential to facilitate the transfer request process (i.e. encourage 24/7 requests rather than post-ward round) and live cot locater information for the in utero transfers coordinated by ScotStar.
• review of employee salaries, salary levels (particularly for on-call payments) and general reimbursement to ensure equity, that the service is on a par with NHS Boards and is able to attract potential employees.

Ongoing work

The ScotStar Neonatal transport service is being reviewed so it supports the final configuration of services, informed by data, and by the final decision with regard to the location and number of NICUs.

Given the complexity and the need for expertise, a small internal group have been considering options for configuring services so that these can be narrowed down to feasible, possible, justifiable and favourable options. This process is ongoing.

Progress Rating

Three of the five recommendations relating to transport have been completed. Recommendation 59 is in progress and relates closely to the new model of neonatal intensive care. Recommendation 55 is currently rated amber. The SPN Transport Group are developing work which will support the aim of this recommendation, and are overseen by the SPN, which is managed by NHS National Services Scotland (NHS NSS) on behalf of the Scottish Government and Health Boards.

Recommendation 55

A standardised risk assessment tool should be developed in relation to any decision on transfer.

Rated: Amber

Delivery: National Delivery

Recommendation 56

A robust national system for the prompt identification of neonatal cot availability, which is accessible through a single point of contact, should be developed.

Rated: Blue

Delivery: National Delivery

Recommendation 57

Nationally agreed pathways for declaring cot availability should be agreed and formal processes should be in place for management of periods of unusually high activity.

Rated: Blue

Delivery: National Delivery

Recommendation 58

All staff involved in neonatal transfers must have appropriate training, with neonatal transfers being subject to regular review and audit processes.

Rated: Blue

Delivery: National Delivery

Recommendation 59

A further, detailed review of transport services should be undertaken, led by the neonatal transport service, to examine the best model for staffing of the service, including the potential for integration with neonatal unit staffing models.

Rated: Blue

Delivery: National Delivery

Remote and Rural Care

Recommendations 60 – 63 relate to remote and rural care. During the review that informed the ‘Best Start’, staff in remote and rural areas highlighted that there are particular challenges which come with working in these environments. The nature of Scotland’s geography means that many Health Boards cover remote and rural areas.

Four recommendations were made by the Best Start on competencies and skills of remote and rural staff, formalising arrangements between remote and rural and urban Health Boards to enable training and development opportunities, use of telemedicine, and incentivising staff to work in remote and rural areas.

Since the Best Start was published, a national workforce strategy for Health and Social Care has been released by the Scottish Government. The Scottish Government is also actively taking steps to support employers across health and social care in rural and island areas to overcome barriers to recruitment. In collaboration with NES’s Centre for Workforce Supply and the National Centre for Remote and Rural Health and Care, a sustained model of direct support that will provide employers with the help they need to improve recruitment success is being developed.

The attraction and retention of people into nursing and midwifery is a key part of the remit of the Nursing and Midwifery Taskforce who have recommended a workplan of actions to improve workplace culture, practice, flexibility, recruitment and retention, alongside the diversification of education and training pathways for each profession to support longer-term workforce sustainability across Scotland, including remote and rural areas.

There are mechanisms to support the recruitment and retention of NHS staff within remote, rural and island areas which have been introduced independently of the ‘Best Start’. The Scottish Distant Islands Allowance is a non-superannuable payment paid to NHS staff who work within island communities. This allowance is paid to assist in the cost of travel to and from the mainland and is a lever which can encourage people to take up employment within those communities. NHS Boards have the facility (in line with HMRC rules) to reimburse relocation expenses.

In addition to the new national strategies, there have been some key achievements under the four Best Start Recommendations 60 - 63. These include:

• a review of the key competencies and skills required for remote and rural working was undertaken. This programme of work included carrying out a literature review to evaluate evidence, then establishing a short life working group to review skills and competencies from a variety of sources and identify any gaps to inform the development of a survey to assess; skills, acquisition and maintenance within the current evidence base and Scottish context. A survey was piloted and rolled out to both urban and rural maternity workforce. There were 150 responses with 76 urban respondents and 68 remote and rural respondents. Final results were presented at the NES conference in 2021: you can watch a recording of the presentation.
• 12 Health Boards reported that they meet the recommendation to have structured arrangements in place, between remote and rural NHS Boards and an urban NHS Board for training and development in identification and management of obstetric and neonatal emergencies. Two Health Boards report that this is not applicable to their circumstances. One Health Board reports that they have a rotation programme available to staff, and also has a skills bus which visits, and carries out skills drills.
• every Health Board reported that they use telemedicine platforms, such as NHS Near Me or Attend Anywhere. Uses include offering antenatal appointments and education, clinics for specific medical conditions, and appointments with specialist services. Boards have reported that generally staff confidence with using the tools is increasing, through experience and training, and staff are confident in their ability to share digital information across health board boundaries to improve care. Some Health Boards also report that they collect and respond to feedback from service users, and other Boards report that they plan to introduce a mechanism for doing so or do so more frequently.
• Covid-19 had an impact on the way care was delivered, with Boards utilising telehealth options to continue to provide care. PHS’s report exploring perinatal experiences during the COVID-19 pandemic in Scotland found that midwives who were self-isolating or shielding had been able to continue to provide care via telehealth, Near Me or other remote means.

Improving the delivery of Obstetric Emergency and Neonatal Resuscitation Role Mandatory Training has been a focus in NHS Highland. To do so, the team has prioritised delivery of training and education by protecting staff time, has invested Best Start funding in new equipment, employed a new Practice Development Midwife and improved the pool of Scottish Multi-Professional Maternity Development Programme (SMMDP) instructors and key local trainers by facilitating the training of other members of staff so they can become instructors. As well as midwives and obstetricians, NHS Highland are training Maternity Care Assistants, GPs, Scottish Ambulance Service staff, and other non-remote and rural practitioners such as Out of Hours GPs and Emergency Department Nurses, Advanced Nurse Practitioners and Rural Emergency Practitioners. By equipping multi-disciplinary staff with the necessary knowledge, skills and competence to cope with emergency situations, NHS Highland are able to provide safe, respectful, and women-centred care throughout the continuum of pregnancy, childbirth and the postpartum period across the remote and rural areas of their Health Board. NHS Highland has provided a real-life story from a community midwife of the benefits of this approach in practice:

“I was able to provide emergency care to a woman in her own home who was having a secondary post-partum haemorrhage, with confidence that I was dealing with the bleeding appropriately and providing high-quality, compassionate, person-centred care. I was able to facilitate her transfer to hospital for ongoing monitoring and was praised by the Obstetric Registrar on arrival, for having arrested the bleeding and done everything that was required to stabilise the patient. This enhanced the experience for the woman and her family, minimised the amount of work for the admission staff and reduced the total blood loss for the woman, along with reducing the risks of further haemorrhage. Having attended, and then being faculty, on local obstetric emergency training courses, I was able to work seamlessly along with GP and Scottish Ambulance Service colleagues who I had trained with. I was also able to collaborate with Obstetric Staff in the main unit, knowing the correct lines of communication and the importance of their role and supportive involvement.

“Attending Obstetric Emergencies Training was the key to success in providing high-quality care to the woman and her family following this emergency call. It also provided me with confidence and job satisfaction, as the woman and her family were extremely grateful.”

Progress Rating

Three of the four recommendations relating to remote and rural care have been completed.

Recommendation 63 is rated green, and work is underway. The Scottish Government is actively taking steps to support employers across health and social care in rural and island areas to overcome barriers to recruitment. A sustained model of direct support is being developed by the Scottish Government alongside NES’s Centre for Workforce Supply and the National Centre for Remote and Rural Health and Care.

Recommendation 60

A systematic review of the additional key competencies and skills that are required for remote and rural staff should be undertaken and training provided.

Rated: Blue

Delivery: National Delivery

Recommendation 61

Structured arrangements should be in place between remote and rural NHS Boards and an urban NHS Board for training and development.

Rated: Blue

Delivery: Local Delivery

Recommendation 62

A working group should be set up to explore the potential for enhanced use of telemedicine in maternity and neonatal services.

Rated: Blue

Delivery: Local Delivery

Recommendation 63

Consideration should be given to development of incentives or bursaries to encourage staff to work in those areas.

Rated: Green

Delivery: National Delivery

Planning and Supporting the Workforce to Deliver

The Best Start set out that new model of maternity and neonatal care can only be successfully delivered if the workforce is suitably supported to do so. Workforce planning, education and training are each relevant, and the Best Start made three recommendations for national action ( Recommendations 64 – 66), which support planning at a local level.

Key successes include:

• the Real-Time staffing resource that was launched by NES in February 2024, which is designed to help Health and Care services to meet the requirement to assess real-time staffing and risk, specified in the Health and Care (Staffing) (Scotland) Act 2019.
• digitalisation of the Maternity-Specific Real-Time Staffing Resource, which is led by HIS. Work is also progressing on the redevelopment of the maternity staffing level tool. It is expected to be delivered in 2024/25. Updates have also been made to the extant Staffing Level Tool as well.
• NHS Education Scotland (NES) published the Review of Midwifery Workforce and Training in March 2021, commissioned by the Chief Nursing Officer Directorate of the Scottish Government.
• in March 2024, the Scottish Government confirmed the implementation of the Agenda for Change Review Recommendations, including the implementation of a consistent approach to Protected Learning Time across all NHS Scotland Boards. This includes the completion of statutory, mandatory and profession specific training within working hours. These provisions were effective from 1 April 2024. Boards should be working through their Area Partnership Forum to put all the agreed aspects of the new policy in place as quickly as possible.

Progress Rating

Two of the three recommendations regarding planning and supporting the workforce to deliver have been completed. Recommendation 64 aligns with wide-ranging work on staffing resources, and the redevelopment of the maternity staffing level tool is under development and should be delivered in 2024/25. Once finalised, the resources will support Boards to complete workforce planning.

Recommendation 64

NHS Boards will require to undertake comprehensive workforce planning based on the new model.

Rated: Amber

Delivery: National Delivery

Recommendation 65

Planning for education and training capacity should take place with NES and the universities, colleges and other training providers, to enable NHS Boards to build capacity where it is needed in time to deliver the new model.

Rated: Blue

Delivery: National Delivery

Recommendation 66

Consideration should be given to the provision of protected training time for all staff to ensure training is given the appropriate priority.

Rated: Blue

Delivery: National Delivery

Continuous Quality Improvement

Recommendations 67 and 68 relate to data and audit systems, which in turn should be used to support continuous quality improvement. Work on these recommendations has been led by the National Evidence and Data Subgroup of the Best Start Implementation Programme Board, and by Health Boards.

A number of developments have been made, including the following.

Development of Maternity and Neonatal Dashboards

• the Maternity and Neonatal Data Hub team at PHS developed core maternity measures for incorporation into dashboards. Such measures, using all-Scotland-comparable data, support individual services and regional collaborations to learn from each other’s experience. Measures were agreed in November 2019 with a short-life working group including representation from Heads of Midwifery, Clinical Directors of Obstetrics, the Scottish Perinatal Network and the Best Start Implementation Programme.
• from 2020 many of the core maternity measures were presented on a Wider Impacts (of COVID) dashboard. Pregnancy and Births and Babies sections of that dashboard were updated each month until September 2023. Those two sections were replaced in October 2023 by a new Scottish Pregnancy, Births and Neonatal Data (SPBAND) Dashboard. Data on SPBAND is refreshed quarterly (in January, April, July, and October each year) by the PHS Maternity Analytical Team.
• SPBAND includes the same topics as those that featured in the two sections of the Wider Impacts dashboard it replaces: Pregnancy - number of pregnancies booked; gestation at booking; number of terminations; gestation at termination; and Births and Babies - location of extremely pre-term births; induction of labour; type of birth; third- and fourth-degree perineal tears; pre- and post-term births; stillbirths and infant deaths; Apgar scores (the first postnatal check).
• PHS continue to maintain a Topics Index. This contains a list of core maternity measures and catalogues individual maternity and neonatal measures already available, including those on SPBAND, Health in the Early Years in Scotland, Discovery, NMPA, NNAP and PHS websites.
• additional data will be added for two neonatal core measures once it is available.

The development of data dashboards has had positive impacts for trend identification. Inclusion of maternity and neonatal measures on the publicly accessible Wider Impacts (of COVID) dashboard allowed timely monitoring of these key outcomes during the Covid-19 period, when there was substantial uncertainty about potential impacts on maternal and infant health. Through the dashboard, concerning trends in neonatal mortality were identified in 2021, enabling prompt assessment of these.

PHS has collected feedback on SPBAND and the Pregnancy/ Births and Babies components of the earlier Wider Impact dashboards. Some of the positive responses include:

• “Thank you for developing such a great resource and for working with everybody to make it as user-friendly as possible…SPBAND is a good tool to compare Health Boards and to see the trends / changes.” (Chair of a Maternity Experience Group on presenting data which is accessible to service users)
• “Very user-friendly and easy to navigate and understand” and “As Director of Midwifery in a large, busy maternity service, it is vital that I have easy access to reliable and robust data – while we have our local real time data available to us, it is crucial that we are able to compare our outcomes and process measures with other maternity services across Scotland. This comparison is a helpful tool in understanding where we need to focus our attention in terms of service and quality improvement and helps us understand wider trends.” (Director of Midwifery)

Significant Adverse Event Reviews

Recommendation 68 was that Health Boards should ensure that the systems and processes in place within their Board to report, record and review all adverse events, are relevant, and applied to, adverse events in maternity and neonatal care, and that systems are in place to share and act on learning. The Scottish Government and HIS published Learning from adverse events through reporting and review: A national framework for Scotland in 2018, setting out the national approach to learning from significant adverse event reviews (SAERs).

To support the process of perinatal adverse event reviews, operational guidance was published by the Scottish Government in consultation with HIS in 2021. The aim of this document is to support Boards to apply a consistent approach to operationalise undertaking perinatal adverse event reviews incorporating the additional reporting required of maternity services, for example to the UK Perinatal Mortality Review Tool (PMRT).

• 11 Health Boards report that they have systems and processes in place to implement the Maternity and Neonatal (Perinatal) Adverse Review Process for Scotland. Three Health Boards report that this is in progress.
• all Health Boards report that plans for staff training are in place and that training is underway.
• 13 Health Boards report that they have external input into Significant Adverse Event Reviews (SAERs) in Maternity. 12 Health Boards report that they have external input into Neonatal SAERs, and one reports this is delivered through the PMRT too.
• all Health Boards report being part of the national learning process, supported by the SPN., with many providing good examples of how SAER learning is being shared both within their Board and more widely. A scoping report on learning from Boards and recommendations for further improvements to SAER processes across Scotland was published by the SPN in December 2023.
• NHS Lanarkshire report that their staff have chaired national learning summaries and, with NHS Dumfries and Galloway, the Scottish Midwifery Leadership Group Risk and Improvement network builds peer support on the SAER process for midwives across all Boards.

NHS Dumfries and Galloway have taken a number of steps to implement the Maternity and Neonatal (Perinatal) Adverse Review process for Scotland. Staff training has been one area of focus: staff training is undertaken in a multi-disciplinary format, and staff have been trained in compassionate conversations which has enhanced their ability and confidence in delivering difficult news. In addition, access to lead reviewer training has been provided by the in-house patient safety and improvement team which has increased capacity and has reduced person dependency on processes. NHS Dumfries and Galloway have also reviewed governance routes, adverse event sign-off and Incident Review Reporting documents to ensure compliance and alignment with the guidance and organisational assurance. Work has been done to re-define incident codes on the Datix reporting system to allow extrapolation of maternity/gynaecology/neonatal incidents. This has allowed for more accurate reporting to the Board’s Healthcare Governance Committee on adverse events opened/closed in specific time periods. Dumfries and Galloway have been members of the Scottish Perinatal Network SAER Working Group and have contributed to the development of learning materials. As a result of this work, there has been an increase in consistency and quality of reports produced, whilst being inclusive of family questions or comments and allow for individualised circumstances.

Progress Rating

Both recommendations relating to data and audit systems have been completed. There is ongoing work to add additional neonatal core measures to the SPBAND dashboard, and PHS will continue to refine and update the dashboard. The tool has been positively received by users.

Recommendation 67

National-level maternity and neonatal dashboards should be developed to facilitate benchmarking and reduce variations in care.

Rated: Blue

Delivery: National Delivery

Recommendation 68

NHS Boards should ensure that the systems and processes in place within their Board to report, record and review all adverse events in maternity and neonatal care, and that systems are in place to share and act on learning.

Rated: Blue

Delivery: Local Delivery

Information Technology, Data and Telemedicine

The Best Start made four recommendations (69 – 72) in relation to information technology, data and telemedicine.

The Best Start recognised that up-to-date and accessible information would be needed to inform improvements in services, to monitor equity and inform strategies and to help reduce inequalities. Recommendation 69 and 70 related to data and audit and have been taken forward by the Scottish Government and the Evidence and Data Subgroup.

National Maternity and Perinatal Audit

The Best Start recommended the new national maternity and perinatal audit (NMPA) may be able to provide focused audits on key issues, and thus this should be explored. A contract was agreed with NMPA to include Scotland. The NMPA is commissioned by the Healthcare Quality Improvement Partnership as part of the National Clinical Audit and Patient Outcomes Programme on behalf of NHS England, the Welsh Government and the Scottish Government. The Scottish Government sits on the advisory group of the NMPA, which provides sprint audits on a range of topics.

National Data Hub

The Evidence and Data Subgroup, led by PHS, led the work to develop a national data hub. Engagement in 2018 with the maternity and neonatal services community defined what a data hub should include. The hub was established in 2019 as a collaboration involving five delivery partners (the SPN, HIS, the Scottish Government, National Records of Scotland, and PHS), with close links to UK-wide audits and IT system suppliers.

The Scottish Government funded (2018/19 to 2023/24) a programme with five workstreams.

1. Manage a visible Maternity and Neonatal Data Hub for Scotland partnership

A PHS-based Hub team manage inter-project dependencies and maintain links to similar work in England, Wales, and Northern Ireland.

The Scottish Perinatal Network host web pages edited by MatNeo Data Hub: https://www.perinatalnetwork.scot/data.

2. Align Maternity and Neonatal data collection, extraction, and data flow

A Maternity and Neonatal Data Access Liaison Group for Scotland (MaNDALS) was established to share updates from multiple parallel conversations involving organisations who require all-Scotland-consistent data for national purposes from clinical information systems (mainly BadgerNet), and to align these conversations.

PHS will soon introduce an automated way to routinely bring nationally consistent maternity and neonatal data from clinical systems into PHS. National Services Scotland Digital and Security (NSS: DaS), colleagues in NHS Boards, and System C (who acquired Clevermed in February 2023 and who provide the BadgerNet systems) are involved in this work.

A Data Services Agreement between PHS and System C will facilitate access to maternity and neonatal data that System C hold on behalf of Scottish NHS Boards, where Boards ask System C to allow access.

3. Establish new all-Scotland maternity data sets

Throughout 2019 PHS reviewed the national maternity data return (SMR02) and the Scottish Birth Record (SBR; national baby data set) to develop enhanced data sets that align to current service delivery, and provide more consistent data on maternity care, births and babies.

When Covid-19 hit, the Enhanced Maternity Dataset for Scotland (EMaDS) work to capture data was refocused on antenatal booking. Weekly Antenatal Booking Collection (ABC) reporting was established, and PHS received historic data back to April 2019, so they could report on all women pregnant in March 2020 (and thereafter).

PHS have created an expanded Version 2 of ABC and developed a Mother, Birth and Baby (MoBBa) dataset. MoBBa will be deployed alongside the existing SMR02 to gather additional data that is not included in SMR02. They will assess if ABC2 and MoBBa are fit-for-purpose by obtaining one-off data transfers for each dataset.

In parallel, PHS have continued to explore how data on miscarriage from ‘early pregnancy’ settings can be captured. This work is funded separately.

4. Routine collection of data on specialist neonatal care

Establishment of a routine collection of a new neonatal care dataset is underway. In November 2019, a one-off data extract from BadgerNet Neonatal was received and analysed to see what changes were needed to a draft dataset developed in 2018/19.

A dataset suitable for routine submission has been agreed, and work has commenced with System C (and NSS:DaS) to start collecting this data.

5. Data displays showing maternity and neonatal CORE measures

(See Recommendation 67: Development of Maternity and Neonatal Dashboards.)

A national MatNeo Data Hub has been developed, yielding these benefits:

• data easier to find via one place.
• data easier to use. Consistent data available for population health monitoring, audits, research etc.
• more unified user experience. Common approach to data presentation.
• better-quality data.
• clarity on data gaps.
• reduced duplication (of data collection). Visibility of where duplication can be removed.
• more efficient use of resource.
• easier to access support.

The Antenatal Booking Collection (ABC) is now a routine all-Scotland data collection. Numbers of pregnancies booked, and gestation at booking, are presented on the Scottish Pregnancy, Births and Neonatal Data (SPBAND) Dashboard and in the annual Antenatal Booking in Scotland publication.

ABC has allowed, for the first time, the identification of the cohort of women in Scotland who are pregnant at any given time. This was crucial to the surveillance and research approach undertaken in the COVID-19 in Pregnancy in Scotland (COPS) study, which provided vital evidence on Covid-19 infections and vaccinations in pregnancy. This dynamic cohort approach is being continued and ABC data is included in the Scottish Linked Pregnancy and Baby Dataset (SLiPBD).

Positive feedback on the Data Hub includes:

• “High quality data is key to service improvement. The MatNeo Data hub is a key part of our perinatal landscape in Scotland.” (Director of Midwifery)
• “MatNeo Data Hub products have been immensely valuable to me for some time. Throughout its development the MatNeo Data Hub has been a great example of collaboration and partnership working to deliver benefits for our wider perinatal community, e.g. the joint development of a national neonatal dataset (NeoCareIn+) between the MatNeo Data Hub team at PHS and the Scottish Perinatal Network.” [Perinatal Network]
• “The development of the data dashboards and hubs are essential to Scotland being able to map, understand, interrogate and improve the care we provide. The progress made over the past few years is so valuable, never more so than during COVID.” (RCM in Scotland)

Recommendations 71 and 72 relate to information technology and systems recommendations. Recommendation 71 is that a single maternity care system for Scotland should be developed, and Recommendation 72 is that a Scottish electronic women’s maternity record be developed. At the time of publishing in 2017, most units used the BadgerNet system. That system has functionality to allow women to view their own records. It is now the case that 13 of the 14 Health Boards have a contract with BadgerNet. NHS Lothian continue to use Trak as their digital patient management system.

Progress Rating

Two of the four Best Start recommendations made in relation to information technology, data and telemedicine have been completed. Recommendations 71 and 72 are amber due to one Board using a different digital patient management system. Though the system differs, women and professionals in all parts of Scotland do have access to an electronic maternity record.

Recommendation 69

The potential to use the new national Maternal and Perinatal Audit to provide focused audits on key issues should be explored.

Rated: Blue

Delivery: National Delivery

Recommendation 70

A national data hub should be developed.

Rated: Blue

Delivery: National Delivery

Recommendation 71

A single maternity care system across Scotland should be developed.

Rated: Amber

Delivery: National Delivery

Recommendation 72

A Scottish electronic women’s maternity record should be developed.

Rated: Amber

Delivery: National Delivery

Managed Clinical Networks

Recommendations 73 and 74 relate to managed clinical networks.

When the Best Start was published, there were three neonatal Managed Clinical Networks. To improve integration and national leadership, the Best Start recommended a single Neonatal Network for Scotland be created. It was also recommended a single Maternity Network for Scotland be created.

Both of these recommendations have been completed. The National Neonatal Network and National Maternity Network were set up in 2019 and 2020 respectively and are managed together as the SPN by NHS National Services Scotland on behalf of the Scottish Government and the 14 NHS Boards in Scotland. Together, the Networks encourage collaboration across maternity and neonatal services and support the best possible outcomes for mothers, babies and families. The SPN has a detailed work programme and has led on a number of national workstreams related to ‘Best Start’, which are detailed under the relevant recommendations throughout this report. More information about the full range of network activities can be found on their website.

Progress Rating

Both recommendations on managed clinical networks are complete, as the SPN has been established. The SPN is a managed clinical network for both maternity and neonatal services and has a detailed work programme.

Recommendation 73

A single Maternity Network for Scotland should be created.

Rated: Blue

Delivery: National Delivery

Recommendation 74

There should be a single Neonatal Managed Clinical Network for Scotland.

Rated: Blue

Delivery: National Delivery

Further Research

During the review which informed the ‘Best Start’, a number of recommendations for research were identified and eight efficient evidence reviews were undertaken and presented in the report. The topics were: models of care, neonatal care, care across the continuum, care for vulnerable women, maternity care for critically unwell women, interprofessional working, place of birth, and continuity of care.

The Best Start recommended that consideration be given to developing research capacity, and to funding a national programme of maternity and neonatal health service research (Recommendation 75). Work on this recommendation was led by the Evidence and Data Subgroup, who recommended a programme of work, though to date, the recommendations have not been completed. Maternity and neonatal researchers can continue to access support in Scotland through the Chief Scientists Office and at a national level through the National Institute for Health and Care Research. Chief Scientists Office also continues to fund the Reproductive Health and Childbirth research network which supports delivery and promotion of high-quality clinical research and studies in Reproductive Health and Childbirth.

The final recommendation of Best Start was that the recommendations and their implementation be evaluated for impact on outcomes and experiences of women, babies, families and staff, and resources (Recommendation 76).

Throughout the implementation process, the Best Start Programme Board has commissioned and considered implementation progress reports which provide information about the status of delivery of Best Start recommendations at a local and national level.

Work on the recommendation to evaluate Best Start was started by PHS, who were commissioned to develop an Evaluability Assessment (EA) which set out options for evaluation. The Scottish Government is developing an evaluation approach informed by the EA and has brought together an Evaluation Advisory Group to support and inform the evaluation of the ‘Best Start’, providing oversight and quality assurance.

The membership of the Group consists of analytical and policy officials from the Scottish Government, statutory and third sector partners, and academics with expertise in midwifery and maternal health.

Best Start recommendations with different implementation timelines will be evaluated, including recommendations that are due to conclude in 2024 and those that are on a longer implementation trajectory, e.g., the new model of neonatal care (by 2026) and continuity of carer (mid-2026). For recommendations where implementation is continuing beyond 2024, consideration will be given to what would be required to enable any further evaluation to be carried beyond 2026, with measures put in place where it is feasible to do so.

It is expected that the evaluation programme will run until 2026, and results will be compiled into a report which will be published.

Progress Rating

Recommendations for further research were made in the Best Start, and the Evidence and Data Subgroup of the IPB recommended a programme of work in relation to maternity and neonatal research. This has not yet been taken forward, however, an evaluation in line with Recommendation 76 is underway and an evaluation strategy will be published in 2025.

Recommendation 75

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.

Rated: Red

Delivery: National Delivery

Recommendation 76

The recommendations and their implementation should be evaluated for impact on outcomes and experiences of women, babies, families and staff, and resources.

Rated: Amber

Delivery: National Delivery