Maternity and Neonatal Redesign Engagement Report

Background

Nottingham University Hospitals (NUH) have prepared an outline business case to secure £29.6m capital funding to invest in neonatal and maternity services at their sites, including Queen’s Medical Centre (QMC) and Nottingham City Hospital.  In particular, the scheme will:

• Provide sufficient capacity for those network babies who are currently sent out of network for their treatment due to capacity constraints (an average of 116 per year based on 2018-2020), to be cared for within the Nottingham Neonatal Service.
• Ensure that the QMC Neonatal Unit achieves the required 2,000+ Critical Care (level 1) cot days per year as required by the NCCR, so those babies predicted to need intensive care can be delivered and cared for at the QMC, rather than the City Hospital.
• Provide sufficient capacity to allow the QMC Neonatal Unit to operate at the national standard 80% occupancy rate, reducing the current extremely high levels of occupancy.

The proposed change to neonatal and maternity services seeks £29.6m capital funding for investment in neonatal and maternity services at the Queen’s Medical Centre (QMC).  This scheme will provide an increase in 21 neonatal cots (from 17 to 38) and eight additional maternity beds, enabling the Trust to provide sufficient capacity to meet the requirements of the Neonatal Critical Care Review (NCCR) and the recent Getting It Right First Time (GIRFT) report. 

The proposals were shared by Nottingham and Nottinghamshire Clinical Commissioning Group (now known as NHS Nottingham and Nottinghamshire Integrated Care Board, and hereafter referred to as NHS Nottingham and Nottinghamshire) with the Nottingham City Council Adult Health and Social Care Committee and Nottinghamshire County Council Health Scrutiny Committee, in November 2021.  It was agreed that targeted engagement would be appropriate to support the planned service moves, especially given the plans for formal public consultation around the longer-term proposals under Tomorrow’s NUH, that would incorporate the vision for maternity and neonatal services.

Tomorrow’s NUH is Nottingham University Hospitals NHS Trust’s programme to create a modern, fit for purpose hospital estate that will allow the most effective and efficient patient care whenever needed. The vision through the Tomorrow’s NUH clinical model is that all women’s and children’s services would be consolidated on a single hospital site (QMC). This long-term strategy for these services is also reflected in the ICS Community and Clinical Services Strategy.  These proposals will be subject to public consultation (date to be confirmed) and the plans within this proposal around neonatal and maternity services are consistent with that vision, whilst not pre-empting the outcome of consultation. 

NHS Nottingham and Nottinghamshire have engaged with community groups, women and families, health and social care professionals and the wider public, to understand views and experiences of neonatal services within Nottingham and Nottinghamshire County and also bordering counties where families may access the sites. The insights generated will inform the development of the proposal outlined above.

Methods

Engagement work commenced on the 27 June 2022 and concluded on the 28 July 2022.

The Engagement Team used various approaches to gather feedback including: –

• An online survey (a total of 138 surveys were completed by members of the public and 30 surveys completed by staff members).
• A webinar for members of the public.  This session was recorded and shared on NHS Nottingham and Nottinghamshire YouTube channel.
• The Engagement team attended forums in Newark and Sherwood and groups in Mansfield, who were meeting either virtually or in a community socially distanced setting, to gather face-to-face feedback. 
• A total of around 20 parent views and opinions were recorded via face-to-face meetings.

Findings

What did members of the public say?

1. Patients and families explained that their current experiences at NUH Maternity Services were positive.
2. The expansion of the facilities would be excellent and provide the care and support needed to babies at a local level.
3. Extending and improving current services, and minimising families being transferred further away from their home for neonatal care, would be excellent and welcomed.
4. Patients and families said that sufficient space needs to be available on sites, to provide better experiences whilst visiting maternity and neonatal services.

What did members of staff say?

1. Overall, staff members working at the maternity services were supportive of the planned redesign of the maternity and neonatal facilities.
2. Comments and feedback received noted the need around staffing levels and retention and recruitment of staff, together with sufficient training of staff.
3. Feedback from staff raised concerns around the use of children’s surgical operating theatres. 

Conclusion and recommendations

Conclusions:

A key theme emerging from all the engagement activity carried out was that the extension of the facility would be welcomed, to ensure there is minimal impact on families, and to also allow- the capacity of the neonatal service to extend to meet demand, as and when required.  Comments and feedback also recommended that the facilities should be staffed appropriately with the right levels of experience and expertise, both in maternity and neonatal services, and a sustainable workforce plan would be needed to ensure this.

Recommendations:

1. Develop a sufficient and retainable workforce plan of staff currently employed, together with consideration of their training needs.
2. Ensure there is adequate and safe space around cots in the neonatal unit, ensuring easier access for staff to provide care, and for families to feed babies.
3. To continue to promote clear and consistent communications between staff, women and families, in order to keep people informed of the changes and updates of the programme of work.    

NHS Nottingham and Nottinghamshire undertook a programme of engagement activity with community groups, women and families, health and social care professionals and the wider public, to understand their views and experiences of neonatal services within Nottingham and Nottinghamshire. The insights generated will inform the development of the future provision.  The engagement work commenced on the 27 June 2022 and concluded on the 28 July 2022. 

As part of the capital planning and prioritisation exercise for 2021/22, the Trust has received an initial allocation of £5m to support the Full Business Case (FBC) development and enabling works for this programme.  The enabling works will ensure those services currently located within the development zone immediately adjacent to the QMC Neonatal Unit, are relocated.  This includes Clinic 3, some Fertility services and a small number of Gynaecology outpatient clinics.

The reconfiguration will lead to the re-categorisation of the QMC as a Tertiary Neonatal intensive Care Unit (NICU), and the City Hospital as a Local Neonatal Unit (LNU).

The main driver for this development is the provision of safe neonatal care for the population of Nottinghamshire, which cannot be guaranteed in a “do-nothing” scenario, given the limitations of the current cot capacity. Tomorrow’s NUH will provide a long-term solution, but the timescales are too protracted for the pre-term babies requiring care in the meantime.

National standards set out in the Neonatal Critical Care Review (NCCR), published at the end of 2019, dictate that to retain status as a Tertiary NICU, a unit must provide at least 2,000 intensive care cot days per year. QMC just about achieves this level of activity currently, but the City Hospital does not. Under the MNR plans, the QMC would be secure in retaining its Tertiary NICU status, and the City Hospital facility would be re-categorised as a Local Neonatal Unit (LNU), i.e. babies could be supported in intensive care at City for up to 48 hours, but would then need to be transferred to the QMC for longer term care, if required.

The plans would create one large unit at the QMC, focused on NICU babies, and one medium sized unit with four special care cots, to allow babies to be treated up to 48 hours in an intensive care unit.

A report was presented to City and County Health Scrutiny Committees (HSC) in November 2021, who welcomed the report informing them of detailed consideration of the neonatal services.  Recommendations from the HSC indicated working with Healthwatch Nottingham and Nottinghamshire to carry out a targeted piece of engagement work, to understand current experience of the services provided and ascertain feedback of the improvements proposed. 

The overarching aim of this engagement work was to understand the current experiences of service users and staff, noting the improvements that needed to be made to inform commissioners and NUH.

This can be broken down into the following objectives:

• To provide patients, members of the public and carers with the opportunity to state what the neonatal and maternity services mean to them, and how they want to access care.
• To provide Primary Care staff and providers with an opportunity to feedback on the Maternity and Neonatal Redesign Programme.
• To understand service users’ experience of maternity and neonatal services, particularly those experiencing health inequalities.
• To work in partnership with Healthwatch Nottingham to ensure we reach our communities, specifically our underserved and ethnic communities and provide opportunities for them to provide feedback.

NHS Nottingham and Nottinghamshire are committed to actively engaging and listening to the views of service users and carers within the community. The key communications and engagement activities that took place included:

• Extensive stakeholder mapping to ensure feedback was sought from those in boundary counties.
• Providing information about the MNR programme to patients, members of the public and carers, including via service providers, community and voluntary sector (CVS) organisations, ethnic and diverse community groups, local authorities (including district councils), NHS Trusts (including Institute of Mental Health at Nottingham University), charities, local community groups and Healthwatch including the Maternity Voice Partnership.
• Making materials available in alternative formats upon request.
• Social media promotion and information available on websites.
• Information cascaded through local CVS, council and system partner newsletters and bulletins and social media opportunities.

Engagement was undertaken as follows:

• A survey which ran from 27 June 2022 to 17 July 2022. In total, 138 responses were received from the public survey and 30 responses received from the staff survey.
• Posters were produced and placed in prominent places across the Trust, to encourage staff and the public to provide feedback.  Information was available in alternative formats and languages as requested.  Internally, the survey link was promoted through a range of channels such as newsletters and social media groups. An outline of responses and graphics of the results and comments received are outlined below.
• Webinars were also run by NHS Nottingham and Nottinghamshire ICB, supported by NUH clinical and operational colleagues.
• Specific Community Meetings – Homestart Group Sessions in Newark and BABES Group at Mansfield Children’s Centre.
• Attendance at Best Start, Newark and Sherwood Forum to share information with key partners.
• Meetings with key groups – Maternity Voice Partnership and Nottingham Women’s Centre.
• Information was shared via system partners newsletters and social media platforms.

81 people out of the 138 survey respondents chose to complete the question which asked whether they supported the redesign plans. 65 respondents (80%) supporting the planned redesign of the neonatal facilities 12 people (15%) were neither supportive nor unsupportive of the plans, 3 people (4%) slightly opposed the plans with only 1 respondent (1%) opposing. Comments from respondents included themes specifically around current services, highlighting smaller units with poor support.

Survey Demographics

73 people completed the demographic section of the survey with the majority being of white ethnicity (93%). Although the majority of the respondents were noted as predominantly of white ethnicity, other ethnic backgrounds were indicated, including members from the Gypsy or Traveller Community, Mixed White and Asian, Mixed White and Black African, Mixed White Caribbean and other Asian background. 75 respondents chose to complete this question with 65 respondents choosing to skip it.

Respondents were asked to indicate which age bracket they fell into with the range being from 18 – 54. 3% of respondents were between the age of 18 – 24, 59% of respondents were between the age of 25 – 34, 35% of respondents were aged between 35 – 44 and 3% of respondents were aged 45 – 54.

The table below indicates the residence of respondents within the County, with the majority of respondents residing in Rushcliffe (24%), Gedling (22%) and the lowest response rate being from Mansfield (3%).

A thematic analysis was conducted for the survey results. The main themes are highlighted within the report. Further information is also available on our website at: Home – NHS Nottingham and Nottinghamshire ICB. Updates and progress of the redesign programme will be available in due course.

Responses from members of the public

As part of the engagement, we wanted to understand more from respondents who had remained at Nottingham University Hospitals following the birth of their babies to receive care. In total, 44 respondents completed this question, with 35 (80%) of the respondents indicating that they had remained at Nottingham University Hospitals to receive care, and 9 (20%) of the respondents were transferred with their baby to an alternative hospital (3 of these indicated yes on the question and 6 respondents provided further information). 94 respondents choose to skip this question.

The overall response from respondents was positive about the care received, however, some negative comments were received.

The data also suggested that resources such as space, parking and parent accommodation could be improved. Further concerns were raised about the importance of preventing the need for families to be transferred or separated during their care. There was also skepticism about the extent to which personal choice was an option for the families using the service.

Below are comments obtained from parents using the service, confirming the perceived need for increased capacity and improved facilities in terms of benefits, improvements and concerns.

Benefits

There were clear main themes from respondents around more space, more beds and more staff present for parents and their babies which would benefit service users, resulting in less transfers and improvement on mental health wellbeing for families.

“A better environment for the babies, less risk to babies from cross infection. A better environment for families.“

People felt that the facilities at NUH are not fit for purpose, with some suggestions for improvements including more space for breastfeeding, bigger sized birthing pools and more parental accommodation.

“It’s a stressful and confusing time for parents, so having the space to move would help with easing stress.“

Concerns and Improvements

Whilst the proposal for an increase in the number of cots on the unit was welcomed, this caused concerns for many women completing the survey, specifically around staffing and the training of recruited staff, and the potential increased difficulty in accessing specialist nurses on the unit. Respondents expressed the need to increase the workforce. Concerns were also raised around the location and choice of where to deliver their babies together with access to parking.

“I am in a slight support, as along with the expansion, you need to hire appropriately too. Great to expand, lots of benefits like more space for women who are having a prolonged labour or for emergencies, but you need to provide adequate care staff to match it.”

Responses from members of staff

There was a total of 30 survey responses from members of staff, with a split across the Queen’s Medical Centre 16 (53%), Nottingham City 5 (17%) and 9 staff members working across both sites 9 (30%). Overall, 21 respondents (72%) of the staff were supportive of the planned redesign, and 6 members of staff (20%) opposed the plans outlined.

The respondents from the staff survey shared their views and comments, with location, resources, the plans to improveme facilities and workforce capacity highlighted as areas of concern. A further suggestion that was noted and considered included the use of alternative locations whilst work is undertaken.

Staff were asked what they felt were the main benefits of the redesign for families and their babies, as well as for themselves.

The majority of respondents were supportive of the proposals, with a high level of comments noting that this would not only create a better working environment, but also a better environment for patients and families. Staff felt that the proposed MNR Programme would improve patient experience, quality of care and the overall patient pathway.

Comments also reflected that this would allow an opportunity for better training and practice for staff members, improved communication and better retention of staff who are currently employed. and would also lead to having a workplan in place to recruit to the Unit.

The charts below show the staff view of the benefits and concerns in relation to the MNR programme, with patient care and workforce (particularly around recruitment) being the main areas of concern.

The main benefits identified by staff were the improvement of environment for women and families and the quality of care that can be provided if facilities are improved at both sites. The increase of cot facilities will also allow more women and families to be treated in the area, rather than transferring to alternative locations. The increased facility would allow increased staff capacity at the sites and allowing training opportunities for new members of staff, therefore increasing staff retention.

Staff members gave detailed responses about how they felt the MNR programme could affect patient care and safety. Concerns were noted around the current workforce. Comments were received reflecting some families may not want to attend the QMC for specialist treatment, and due consideration needed to be taken into account around patient choice.

Concerns were also raised about the impact on other facilities at the Trust whilst work was undertaken, specifically the disruption to children’s surgical pathways and children’s operating theatre during the redesign period.

“Staffing levels are concerning especially if the buildings are extended“

Staff responses highlighted points around impact on services together with managing waiting lists for surgical procedures. Additional comments from staff around workforce included:

“Office space needs to be considered across all roles including administration’“

Further feedback from staff highlighted concerns around the rotation of staff across both sites, along with challenges that new ward layouts would bring.

All staff were asked a further question of other considerations or comments they would like to highlight, regarding the proposed redesign of neonatal and maternity services at NUH.

Concerns were noted around surgical services resulting in possible delays during the redesign work and increase of waiting lists. Staff were also concerned about support they will receive following the change with wellbeing and opportunities to be involved in decision-making.

Suggestions were made for the need to increase antenatal beds within B26 and the labour suite, as well as increasing theatre space and a quiet room for families. As previously stated, further comments were made around the increased pressure on QMC staff.

Feedback from Community and Representative Groups

As part of the targeted engagement activity, NHS Nottingham and Nottinghamshire engagement team members attended a number of community groups. The feedback of their experiences in accessing neonatal care across both NHS Trusts in Nottingham and Nottinghamshire was mainly positive, with staff being seen to be committed, caring and supportive.

Feedback was also received around how and when communications relating to their care are received, how this is not always patient facing and can include jargon which is not helpful and sometimes can be confusing for women, families, and carers.

Thank you to all participants who took the time to complete the survey and to all who attended the webinars to provide feedback, and to share their stories with us. Thank you to the community groups who allowed us to attend their specific sessions and to those who shared the information on social media platforms.

For a full copy of the survey, please contact: nnicb-nn.engagement@nhs.net