Intelligent Commissioning of Maternity Services How do we make it happen Suzanne Tyler

The key maternity messages Birth rate has gone up 22% in last decade Complexity and risk factors for women (BMI, age, LTC) have increased considerably) Staffing levels in midwifery, obstetrics and sonography vary considerably around the country and in many areas fail to meet national recommendations Outcomes are generally good, with considerable local variation and many opportunities for improving clinical outcomes and experience exist Safety is the highest concern, but womens experience of maternity services impacts longitudinally on health and wellbeing Its a high profile service which excites public and political attention especially around configuration Focus tends to be on the birth event rather than the contribution of antenatal/postnatal care to long term health and wellbeing Implementing policy around choice, continuity, 1:1 care in labour etc has been patchy and there is till much to do There is a good track record of involving users but the voice of GPs has declined over time Links to neonatal services and seamless transitions are essential and much excellent work has been done around the country – but it is not uniform

The Commissioning Challenge: Dame Barbara Hakin: October 2011 The system we are developing gives us a real opportunity to do things differently. I would encourage everyone who is involved with or has an interest in commissioning to really think about how we can be different, how can we use commissioning to give patients much more voice and choice

Liberating the NHS: Legislative Framework and Next Steps December 2010 While responsibility for commissioning maternity services should sit with GP consortia, we will expect the Board to give particular focus to promoting quality improvement and extending choice for pregnant women. The Board will support consortia to work together collaboratively to commission services: consortia will be able to group together, or pool resources with the Board, where this makes most sense. The Board will also directly commission specialist neonatal services* * i.e. the 10% of babies requiring SCBU

Developing the NHS Commissioning Board: July 2011 In addition, the NHS Commissioning Board will host clinical networks, which will advise on distinct areas of care, such as cancer or maternity services. The Board will also host new clinical senates which will provide multi- disciplinary input to strategic clinical decision making to support commissioners, and embed clinical expertise at the heart of the Board. The purpose of these groups is to ensure that clinical commissioning groups and the Board itself have access to a broad range of expert clinical input to support and inform their commissioning decisions. The relationship between the Board and clinical networks and senates is likely to change as the new commissioning system matures. Clear arrangements for key service areas, which would gain particular benefit from dedicated professional and clinical leadership. These might include childrens services, mental health, older peoples services, dementia, learning disabilities, maternity and primary care.

Clinical Commissioning Groups: what we know c260 pathfinders –11 CCGs in every neonatal network? Size range from pop 18,900 to 755,906 –Pop 100,000 equates to approx 1400 births –Pop 200,00 equates to approx 2800 births –Pop 300,000 equates to approx 4000 births Average maternity unit delivers around 3-4,000 babies a year Around a quarter of units deliver over 6,000 babies a year Low level of GP engagement with maternity services to date Direct maternity spend accounts for about 3% of existing PCT budgets

What CCGs are likely to see CCG Population Est births/Year Est births women >35 Est perinatal mortality Est LBWEst LSCSEst maternity spend 100, £3m 200, £6m 300, £9m 500, £15.5m 700, £21.5m

CCGs holding the ring in the new architecture for maternity commissioning Public Health Outcomes Framework Workforce Health Education England Fit with primary care Records, data and IT Smoking Breastfeeding Screening Teenage pregnancy NHS Outcomes Framework Commissioning Outcomes Framework Health Watch Fit with Child health

This project Identify CCGs who would like support to develop maternity commissioning skills and expertise Work with them and other stakeholders to identify skills, tools and learning required Share that learning amongst the CCG network and Commissioning Support Organisations Inform the NHS Commissioning Board in developing its assurance role

Messages so far Confusion about who commissions what –NHS CB: neonatal services and health visiting What about transitional care –LAs: public health (smoking, obesity, teenage pregnancy) –CCGs: maternity – routine and specialist Strong desire for locally provided services Opportunity for shared commissioning arrangements Links with Health & Wellbeing Boards emerging Its all about relationships

Scope for doing things differently Pathway redesign of whole -9 months to 5 years services Better integration of primary, acute based, community based and social care that supports new families A clinical perspective to challenge existing provider behaviour where outcomes vary from neighbouring, regional or benchmarked norms A clinical perspective into provider network discussions about configuration that ensures patients needs are at the heart of decision making ? What about neonatal care?

Likely product Key messages/principles about what is important in commissioning maternity services –Operating & Outcomes Framework –Policy Links to resources, guides and templates that will help –Standard service specs –Benchmarking data –Professional guidance etc Case studies from CCGs already engaged

Example: Aligning local and national priorities 90% of women to have a completed medical and social booking by the end of their 12week 6 day of pregnancy National requirement: links to Operating framework Evidence of 1:1 care in labourLocal requirement: links to Operating & Outcomes Frameworks Increase in normal birth rate and reduction in caesarean section rate Local requirement: links to Operating Framework, Outcomes Framework and QIPP Prioritisation of care for women with BMI >35Local requirement: links to Public Health Outcomes Framework Promotion of choice of place of birthNational requirement: links to Operating Framework and Outcomes Framework Maintaining low rates of perinatal mortalityNational requirement: links to Outcomes Framework Maintaining low rates of Low Birth weight babiesNational requirement: links to Public Health Outcomes Framework Focus on reducing admission of term babies to neonatal intense care National requirement: links to Outcomes Framework Reporting of PROMSNational requirement: links to Outcomes Framework Reducing unscheduled antenatal activityLocal requirement: links to QIPP Implementing SHA Workforce FrameworkLocal requirement: links to Operating Framework & QIPP A focus on preparation for parenthood that aligns to national best practice Local requirement: links to Public Health Outcomes Framework

What do CCGs need so they become informed commissioners of maternity services? What do CCGs need to know about the needs of their local population, as well as local and national requirements and where will they get this information from? How will they know whether the services they commission are safe and of high quality as well as meeting the specific needs of their local population? How will CCGs make arrangements with their local providers to negotiate activity, service models investment decisions and outcome expectations? What do GPs see as the priorities for improving maternity services? How can maternity networks support CCGs in delivering their commitments?

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