Moray Maternity Services Review: report

1 Executive Summary

In March 2021, the Cabinet Secretary for Health and Sport, Jeane Freeman, commissioned an independent review into maternity services for the women and families of Moray: "The Moray Maternity Services Review" (the Review).

The Review Group was commissioned to work with NHS Grampian, NHS Highland, and with stakeholders who have an interest in local maternity services, to describe the best obstetric model that would provide safe, deliverable, sustainable, and high quality maternity services for the women and families of Moray in line with the Scottish Government ambition described in "The Best Start: A Five-Year Forward Plan for Maternity and Neonatal Care in Scotland (2017)" (the Best Start Plan): The best start: five-year plan for maternity and neonatal care - gov.scot (www.gov.scot)

Expected Outcome

The outcome of the Review was to be "a report detailing the best service model or options that offer deliverable, sustainable, safe and high-quality maternity care for the women and families of Moray".

The report should also offer "a recommended action plan that takes the service from its current position, through a series of safe interim steps, before reaching its final configuration".

The Process

The Commission Brief, including a Terms of Reference for the Review^[2] were agreed with Scottish Government, and a Review Group^[3], chaired by Ralph Roberts, Chief Executive of NHS Borders was set up. This group was formed of experienced clinical and senior executive and managerial staff from other NHS Boards in Scotland. No member of the Review Group was working for NHS Grampian or NHS Highland at the time the Review was commissioned. All members have had experience of working in areas which serve remote and rural settings, which has been crucial in understanding and assessing the information provided and evidence gathered.

The Review Group undertook a robust process to support its decision-making and in reaching a conclusion. This included referencing and reviewing all the written evidence provided by NHS Grampian, NHS Highland and a range of stakeholders, and meeting with women and families in Moray, and their advocacy and political representatives. The Executive Leadership Teams of NHS Grampian and NHS Highland were also directly engaged during the course of the Review.

Members and representatives of multi-disciplinary clinical teams from Aberdeen Maternity Hospital, Dr Gray's in Elgin and Raigmore Maternity Unit in Inverness were interviewed and/or offered an opportunity to submit a written statement, as were heads of service at the Scotland Deanery^[4] based in the North of Scotland.

Representatives of both the Royal Air Force (RAF) based at Lossiemouth and the Army's 39 Engineer Regiment based at Kinloss were offered the opportunity to meet with members of the Review Group, or to submit evidence in writing, as was the local Chamber of Commerce.

From all of the information gathered and reviewed, the Review Group formed a long list of six potential models of service delivery for maternity services in Moray:

• Model 1: Status Quo
• Model 2: No Intrapartum Services in Moray
• Model 3: Community Maternity Unit* linked mainly to Aberdeen
• Model 4: Community Maternity Unit* linked mainly to Raigmore ("Moray Networked Model")
• Model 5: Rural Consultant-supported Maternity Unit*
• Model 6: Consultant-led Maternity Unit*

*this unit to be located in Dr Gray's Hospital in Elgin

Model 1 (Status Quo) and Model 2 (No Intrapartum Services in Moray) were promptly considered to be inappropriate and disadvantageous by the Review Group. The Review Group, therefore, focused its time and deliberations in considering the remaining four models of service delivery in further detail.

Conclusion: Short-term

The outcome of the Review Group's in-depth deliberations is the recommendation that, in the short-term, Model 4 is the most appropriate model to be established promptly in order to provide a safe, high-quality maternity service to women residing in Moray.

This decision was reached by taking into consideration all the information provided, and having met with all the interested parties who wished to contribute to the process, coupled with stakeholders' experience and the Review Group's professional knowledge.

This model of delivery will provide stability and clarity to the service, and to all those involved in delivering and receiving the service.

Model 4: Community Maternity Unit* linked mainly to Raigmore ("Moray Networked Model")

• Women are offered a choice of intrapartum care at either Dr Gray's, Aberdeen or Raigmore, with the associated antenatal care provided in Dr Gray's, as appropriate to the complexity of their care requirements.
• Midwife-led and consultant-supported antenatal care in Dr Gray's.
• Midwife-led intrapartum care in Dr Gray's, offering the potential to provide approximately 20% of Moray births (all of these births would be 'low risk').
• No obstetric medical cover for Dr Gray's intrapartum care; and therefore, no facility for Obstetric interventions, such as instrumental deliveries or emergency caesarean sections.
• Access to planned consultant-led intrapartum care shared between Raigmore and Aberdeen as part of a "Network" with a choice of unit, dependent upon a clinical risk assessment, the woman's personal choice and geographical location.
• Consultant-provided elective caesarean sections in Dr Gray's (offering the potential to increase the number of births by a further 20%); This service expected to be provided by consultant obstetrics and gynaecology staffing and supported by the existing theatre and anaesthetic teams. This will also require flexibility of midwife staffing to provide a 24/7 staffed unit as required.
• In the event of emergency or urgent transfers, women will be transferred to Raigmore, unless they are clinically required to transfer to the specialist unit in Aberdeen.

*this unit to be located in Dr Gray's Hospital in Elgin

Conclusion: Medium-term

We have detailed in the main body of this report a model of service delivery that we believe is achievable in the medium to long-term: Model 5. However, this will be dependent on a significant increase in staff recruitment, which is a known challenge across Scotland (and indeed the UK) at the present time.

It is also dependent upon continuous development of Dr Gray's Hospital to enable it to function at a level commensurate with other small, rural district general hospitals in Scotland.

Model 5: Rural Consultant-supported Maternity Unit*

• Midwife-led and consultant-supported antenatal services in Dr Gray's.
• Midwife-led and consultant-supported intrapartum care in Dr Gray's, with the service offered to women who have been carefully risk-assessed and meet agreed criteria to give birth in Dr Gray's. There is potential to provide care for between 50%-70% of Moray women (based on the Scottish Northern Isles' approach).
• Obstetric medical cover available on a 24/7 basis (on-call from home, out of hours). This model, based on risk assessment, includes provision for obstetric interventions, including instrumental births and emergency caesarean sections.
• Elective caesarean section service in Dr Gray's for selected women provided by consultant obstetrician and gynaecologists, and supported by the anaesthetic and theatre teams.
• Links for planned consultant-supported intrapartum care for higher risk deliveries shared between Raigmore and Aberdeen as part of a "network". Choice of unit, dependent upon a clinical risk assessment, and the woman's choice and geographical location.
• In the unlikely event of emergency or urgent transfers, women will be transferred to Raigmore, unless they are clinically required to transfer to the specialist unit Aberdeen.

*this unit to be located in Dr Gray's Hospital in Elgin

The Review Group commend these recommendations for maternity services to the women and families of Moray, and their community and political representatives. The delivery of these recommendations will require the support and commitment of the managerial and clinical staff across NHS Grampian and NHS Highland, as well as their executive leadership teams and the Scottish Government. This will be essential to promote and champion this model, and to support all parties to work collaboratively to ensure it is delivered within the indicative time-frames laid out within this report.

The report is presented to the Cabinet Secretary for Health and Social Care and the Minister for Public Health, Women's Health and Sport for consideration.