The majority of maternity care in Scotland should be delivered in community settings rather than hospitals in future, according to findings from a major review.
In particular, maternity services should in future see “primary” and “buddy” midwives work together in a community team to ensure women are cared for by the same healthcare professionals, according to a key recommendation on care continuity outlined following the major review in Scotland.
“I want to focus in particular on the key recommendation on continuity of midwifery care and we will be moving forward with this quickly”
The new model, which is expected to ensure “continuity of carer”, will see the majority of midwives work in the community, with a small core team of midwives working in hospitals to provide inpatient antenatal and postnatal care, and some intrapartum support.
The change represents a “fundamentally different way of delivering services”, according to the review report, which was published last week and called The Best Start: A Five-Year Forward Plan for Maternity and Neonatal Care in Scotland.
It is expected that midwives in the community will normally have a caseload of approximately 35 women at any one time. Most will work in new community “hubs” that will be designed to ensure woman can access the majority of their antenatal and postnatal care there.
The hubs will be developed based on local needs but could include extended opening hours for appointments, scanning facilities, and in some cases birthing services.
The review, led by NHS Forth Valley chief executive Jane Grant, said it expected the plans could be delivered without a change to the number of midwives and obstetricians.
“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,” said the report.
“In addition, an increased number of support staff may be required to support delivery of antenatal and postnatal care locally,” it added.
“Many [maternity staff members] are going to face significant changes to how and where they work”
Other recommendations in the report include reorganising Scotland’s 15 neonatal units, with 10 to 12 offering local neonatal care and special care for less sick infants.
Meanwhile, three to five of them will be designated as neonatal intensive care units – a reduction from the current eight offering this type of care.
The change is due to the fact the majority babies requiring additional care in Scotland need high dependency and special care services, and only a small proportion require intensive care.
However, for that small proportion, the complexity of neonatal intensive care has increased, said the report.
It noted that condensing the number of neonatal intensive care units would “lead to improved staff competencies and best clinical practice in these units and safer care for the babies most at risk”.
The report also noted the growing importance of advanced neonatal nurse practitioners. “These highly skilled members of staff are a real asset to the current neonatal workforce and further development of these roles would be beneficial to the overall service,” it said.
Manager appointed to lead Scottish maternity review
Among its 76 recommendations, it called for the role of ANNP staff to be reviewed to ensure their skill set is “maximised, with a clear training and development support mechanism to retain and develop staff”.
In addition, it said that non-registered neonatal staff should have a “clear role definition, competency framework, training and skills pathway” to ensure they can “work flexibly across all aspects of care”.
The recommendations also said each NHS board must ensure it was able to provide the full range of choice of place of birth, including at home, in a midwifery unit, or in an obstetric unit.
NHS boards should review access to perinatal mental health services, while “primary” midwives played a “proactive and systematic role” in identifying and managing perinatal mental health care, said the report.
“Our current services have evolved over many years and the time is right for a refreshed model of maternity and neonatal care – based on the current available evidence, best practice and feedback from families and frontline staff to design and further improve existing services,” said Ms Grant, who chaired the review group.
Commenting on the review’s findings, ministers said they would provide a detailed response on “realising” the ideas set out in the report “in the near future”, but said they would focus first “on the key recommendation on continuity of midwifery care”.
“The plan recognises…the need for training, support and time for the workforce to adapt to news ways of working”
Health secretary Shona Robison said the review provided an opportunity to identity best practice and that it also outlined where improvements were needed.
“I want to focus in particular on the key recommendation on continuity of midwifery care and we will be moving forward with this quickly, with early-adopter boards. This move will help build relationship-based care between women and midwives, and will improve outcomes for women,” she said.
The Royal College of Midwives welcome the report, saying the plans had the potential to “revolutionise” maternity services, but acknowledged the shift from hospital to community care would be challenging for staff.
“This is a defining moment for maternity services in Scotland and will be a seismic shift for our maternity services,” said RCM director for Scotland, Mary Ross-Davie.
“What is so important is that this puts women and their families at the centre of care,” she said. ”The focus on continuity of care and carer – that is the woman seeing the same midwife or small group of midwives – is very welcome. There is very strong evidence that better continuity of care leads to better outcomes for the mother and baby.”
But she highlighted that the plan was “going to ask a lot of our maternity staff including midwives, maternity support workers and our colleagues”, with many set to face “significant changes to how and where they work”.
“The plan recognises this, and the need for training, support and time for the workforce to adapt to news ways of working,” she said. ”This is vital because without the support of staff, no system can work effectively.”
Scotland’s report on maternity services follows a national review of England’s maternity provision last year, which also proposed a shift towards more community teams of midwives sharing caseloads.
Seven sites across England were chosen in November to trial the new approaches to services.