1. Introduction

Aims of this document

1.1 To provide advice to integrated care boards (ICBs) and trusts on:

• Fulfilling statutory obligations around involving people and communities in the planning, proposals and decisions regarding NHS maternity and neonatal services in England.
• Responding to the actions and responsibilities laid out in the Three-year delivery plan for maternity and neonatal services.

1.2 To set out areas to consider when commissioning and supporting effective maternity and neonatal voices partnerships (MNVPs).

1.3 To signpost ICBs and trusts to resources on how to set up and sustain an MNVP.

1.4 The accompanying supporting materials bring together resource templates and example role descriptions that have been developed within Cornwall and the Isles of Scilly Local Maternity and Neonatal System (LMNS).

These are kindly shared to support others in their journey towards improving local MNVPs.

What is a maternity and neonatal voices partnership?

1.5 An MNVP listens to the experiences of women and families, and brings together service users, staff and other stakeholders to plan, review and improve maternity and neonatal care.

MNVPs ensure that service users’ voices are at the heart of decision-making in maternity and neonatal services by being embedded within the leadership of provider trusts and feeding into the LMNS (which in turn feeds into ICB decision-making).

This influences improvements in the safety, quality, and experience of maternity and neonatal care.

Background

1.6 Over the last eight years, there have been several major independent investigations into serious harm caused by maternity and neonatal services: University Hospitals of Morecambe Bay NHS Foundation Trust; Shrewsbury and Telford Hospital NHS Trust; and East Kent Hospitals University NHS Foundation Trust.

An overarching theme of all these reports is a failure to listen to service users.

1.7 Significant health inequalities exist in access to and outcomes from maternity and neonatal care in England.

For example, outcomes for women and babies from certain ethnic minority groups are worse than for white women, and outcomes for those living in the most deprived areas are worse than for those in the least deprived (MBRRACE-UK, 2022).

This inequity in outcomes means it is even more important for services to listen to the experiences of these women and their families to ensure services are co-designed to meet their needs.

1.8 There are additional examples of inequalities for those with other protected characteristics: such as those with disabilities, including learning disabilities, and individuals from the LGBT+ community.

They should be able to access their local MNVP and care should be given to hearing and seeking out their voices.

In addition, while most people using maternity and perinatal services are women, intersex, transgender and non-binary people experiencing pregnancy and birth can also experience health inequalities, including poorer access and a lack of information and support for their specific clinical and care needs within maternity services.

[The CQC Maternity Survey (2022) found 0.65% of respondents stated their gender was not the same as their sex registered at birth.]

1.9 The 2022 Review of the funding and function of maternity voices partnerships (MVPs) identified:

1.10 The principles for MNVPs described below aim to help ICBs and trusts address unwarranted variation while ensuring there remains flexibility to design MNVPs around the needs of local women and families.

Policy context

1.11 Working in partnership with people and communities sets out the statutory guidance for ICBs and trusts to meet their public involvement legal duties:

1.12 There are clear benefits to working in partnership with people and communities:

• Better decisions about service changes and how money is spent.
• Improved safety and experience.
• It helps address health inequalities by understanding communities’ needs and co-developing solutions.
• It is about shaping a sustainable future for the NHS that meets people’s needs and aspirations.
• Reduced risks of legal challenges.

1.13 In the three-year plan, NHS England set out its ambition to better involve service users:

• MNVPs listen to and reflect the views of local communities. All groups are heard, including bereaved families.
• MNVPs have strategic influence and are embedded in decision-making.
• MNVPs have the infrastructure they need to be successful. Workplans are funded.
• MNVP leads, formerly MVP chairs, are appropriately employed or remunerated and receive appropriate training, administrative and IT support.

1.14 To achieve these aims, NHS England also set out some expectations of ICBs:

• Commission and fund MNVPs, to cover each trust within their footprint, reflecting the diversity of the local population in line with the ambition above.
• Remunerate and support MNVP leads, and ensure that an annual, fully funded workplan is agreed and signed off by the MNVP and the ICB. All MNVP members should have reasonable expenses reimbursed.
• Ensure service user representatives are members of the local maternity and neonatal system board.

1.15 ICBs have a responsibility to ensure they are delivering on the commitments set out above.

The NHS Resolution Maternity Incentive Scheme Clinical Negligence Scheme for Trusts Safety Action 7 also requires providers to ensure MNVPs function in line with the three-year plan and this MNVP Guidance.

The addition of neonatal voices

1.16 From 2024/25, responsibility for commissioning neonatal critical care services will be delegated to ICBs.

In preparation for this, in May 2022, NHS England published Next steps towards LMNS (via FutureNHS), which sets out plans for greater integration of maternity and neonatal transformation.

It states:

1.17 Neonatal operational delivery networks (ODNs) PAGs are a group of volunteer parents and carers who have used neonatal services within the region.

Establishing PAGs was a recommendation from the Neonatal Critical Care Review. PAGs ensure service user voice is represented in neonatal service design and delivery at a network level.

MNVPs and PAGs will need to develop relationships and work together to ensure neonatal voices are represented at both network and local level and able to continue to influence decisions once commissioning arrangements have changed.

1.18 To support LMNSs to move towards implementing these actions, this document sets out suggestions for the addition of neonatal care to their remit and how to engage and involve neonatal families in quality and safety surveillance at provider and system level.

This is in line with the three-year plan which specifically includes neonatal in referencing MNVPs.

2. Commissioning effective MNVPs

2.1 Below are listed the ambitions and commitments of the three-year plan, accompanied by advice on how trusts and ICBs can meet these ambitions, in relation to involving service users and their specific commitments, and the necessary considerations at each stage.

Some case examples are given in the supporting materials document.

Engagement and listening to families

2.2 One of the main functions of a MNVP is to engage with and listen to families in their community about their experiences of maternity and neonatal care.

2.3 Effective MNVPs will reflect the ethnic diversity of the local population and reach out to seldom heard groups, including those most at risk of experiencing health inequalities, parents with experience of neonatal care, and bereaved families.

2.4 In all cases when an MNVP is carrying out engagement work, it is good practice to have processes in place to record intelligence and demographic data gathered in line with data protection rules, including GDPR.

2.5 Engagement should be accessible and appropriate, particularly for neonatal and bereaved families. This is not necessarily easy and will require a proactive, but sensitive approach.

When reaching out, it is important to consider how people are protected from being re-traumatised through giving feedback on their experience.

This may involve separate opportunities for engagement, plus training for MNVPs to engage effectively and safely so unintentional harm is avoided.

One important way of ensuring that engagement is handled sensitively is to work in partnership with local specialist voluntary, community and social enterprises (VCSEs) which have lived experience.

This can help gather feedback, prevent duplication of work and avoid potential conflict with neonatal PAGs.

2.6 The MNVP lead is responsible for ensuring appropriate risk assessments, safeguarding procedures and training, including a trauma-informed approach, for all people facilitating engagement in the community or within the maternity and neonatal services are in place.

A clear escalation process should be in place that should always be followed and documented if an immediate safeguarding or patient safety concern is disclosed or identified during MNVP outreach and engagement.

This will be available to staff and volunteers who conduct engagement on behalf of the MNVP.

It is good practice to provide a clear list, signposting to local and national support organisations, that can be easily accessed by all staff and volunteers.

NHS England has committed to developing a national support offer for MNVPs and support with these issues will be available to MNVP leads as part of this.

Fifteen Steps

2.7 The ‘Fifteen Steps’ approach is about understanding quality from the perspective of people who use maternity and neonatal services.

It is an observational approach whereby small teams of service users and staff explore local maternity and neonatal settings to get a ‘feel’ for the space and together identify and implement improvements.

Some MNVPs conduct a Fifteen Steps annually in antenatal, intrapartum and/or postnatal care venues plus any neonatal unit on site.

When Fifteen Steps are conducted, outcome reports should be shared with trust governance, safety champions and the LMNS board.

See the Fifteen Steps for Maternity toolkit for detailed guidance.

Walk the Patch

2.8 Walk the Patch is a way of collecting direct feedback from current maternity service users on the maternity unit.

It is intended as a snapshot of women’s experience of care on a certain day on the unit and can be collected from women who have birthed in a birth centre or on the labour ward.

Surveys and digital feedback mechanisms

2.9 Effective MNVPs have an easily accessible and ongoing way to gather feedback. This could be via an ongoing survey or an electronic feedback form.

Feedback is regularly analysed, and the data reported into provider trust governance systems and used to influence improvements of the service.

Short running surveys can also be used for focused projects or specific pieces of work.

Those co-producing MNVP surveys and feedback forms should be cognisant of trauma informed language and accessibility requirements. This may require further training.

Outreach

2.10 Effective MNVPs conduct regular engagement out into the community. This could be at venues of care such as antenatal or postnatal clinics, health visitor clinics or community baby groups as well as larger scale community events.

The MNVP ensures regular engagement sessions across the whole patch served by the provider trust or unit.

MNVP engagement includes neonatal families, bereaved families, marginalised groups and local communities more at risk of health inequalities and adverse outcomes as identified by LMNS equity and equality action plans.

Effective outreach involves covering the breadth of the geographical footprint and being reflective of the size and demographics of the local birthing population.

Partnership working with voluntary, community and social enterprises

2.11 MNVP engagement is most effective when it is accessible and appropriate, particularly for neonatal and bereaved families, where MNVPs work in partnership with local specialist VCSEs with lived experience of gathering feedback.

Training for MNVPs to engage with communities including vulnerable and seldom heard groups may be required for feedback to be gathered appropriately and sensitively.

Social media

2.12 MNVPs can use social media to support their main functions: primarily to engage with and gather insights from families in their community about their experiences of maternity and neonatal care and to share information and communicate with local people.

MNVPs are independent, and often MNVP social media is separate from any trust or ICB-led social media accounts.

MNVP account managers may want to refer to their local ICB’s social media policy for useful best practice principles and guidance, including any considerations in relation to safeguarding.

Thematic analysis of feedback

2.13 Reviewing feedback and data sources regularly enables an MNVP to report on findings to influence decision-making and service improvement.

This includes review of Care Quality Commission (CQC) Maternity Survey data annually, as well as analysis of free text insights from the CQC Maternity Survey.

The MNVP should also liaise with their regional PAGs and care co-ordinator to understand the neonatal service users experience.

Strategic influence and decision-making

2.14 One of the main functions of an MNVP is to participate in and actively influence decision-making on local strategies and policies in maternity and neonatal care.

This section provides some advice on how an effective MNVP can carry this out at different levels within the system.

2.15 ICBs will need to consider how intelligence and influence can be shared across ICB borders where service users access care in a system different from where they live.

Trust-level

2.16 Effective MNVPs have developed strategic influence at trust or unit level.

The role of an MNVP is to bring together intelligence from the activities outlined in paragraphs 2.2-2.13 (Engagement and listening to families) and use that to influence strategic decision-making.

MNVPs also contribute to the quality and safety agenda by providing critical friendship and supporting oversight through the Perinatal quality surveillance model (PQSM).

To do this, the MNVP is embedded within local maternity and neonatal governance. This includes (but is not limited to) safety champion activities, guidelines committees, mortality audits and serious incident response groups.

The MNVP lead is supported to develop and maintain relationships with the senior leaders within maternity and neonatal services and be responsive to any changing local situation and needs of the services.

A clear way in which MNVP leads can influence decision-making is by having them as quorate members of strategic meetings.

LMNS-level

2.17 Service users should have strategic influence at LMNS level.

LMNSs which do this well have a robust feedback loop in place that ensures a clear pathway for how the work of the local MNVP(s) influences and feeds into the work of the LMNS.

2.18 This means formal membership of the LMNS board alongside a formal mechanism to co-ordinate feedback and co-production from all local MNVPs and service users within the system and feed it into LMNS-level activities and decision-making.

It includes involvement with the ICB-level perinatal quality surveillance model (PQSM), shared learning forums and transformation workstreams.

Where the participation of service user voice in the LMNS board and maternity and neonatal quality meetings is required for quoracy, this ensures consistent representation of service user voice.

Leadership

2.19 Each MNVP will need a lead who is a service user. The role of an MNVP lead is:

• taking responsibility for leading and managing the MNVP programme of work
• making decisions on how the budget is spent
• facilitating women and families’ voices to be heard from diverse backgrounds
• with appropriate operational and logistical support, facilitating and fulfilling the MNVP’s responsibilities to engage and co-produce projects with the provider trust/unit
• ensuring that key learning is disseminated, and robust governance processes are followed for decision-making
• being an equal and respected member of the senior leadership team, developing and maintaining professional relationships to enable critical friendship and strategic influence.

2.20 MNVPs will need a lead with the right leadership skills to influence and lead a complex programme of work and contribute to the quality and safety surveillance framework.

It is also important that this role is fulfilled by a person with lived experience of maternity and/or neonatal services, who is not already employed in the local trust or system, for example as a clinician.

2.21 MNVPs might need a leadership team rather than a single individual. This is likely to be the case when different people lead different elements of the MNVP programme in line with their expertise.

Examples might include having a lead responsible for engagement with seldom heard groups or bereaved parents.

ICBs might particularly want to consider how leads are able to shape neonatal services. One way to achieve this is for a separate strategic lead to be appointed for neonatal care.

2.22 ICBs will need to consider how MNVP leads are appropriately remunerated. This requires matching the level of remuneration with the demands of the role. Remuneration can be through:

• employing the lead directly
• self-employment and being contracted in
• contracting a third party who employs the lead.

ICBs will want to make sure payment is in line with government rules on off-payroll working (IR35) if they are not directly employed.

2.23 ICBs have a responsibility to ensure meaningful service user involvement and engagement at system-level and at trust-level.

To fulfil this, different roles could be considered:

• An LMNS service user lead will be responsible for leading co-production and involvement at LMNS level.
• In smaller systems, it could be that the LMNS service user lead is also the MNVP lead.
• In larger systems, extra co-ordination with separate position(s) for LMNS and MNVP lead(s) might be needed.

See the supporting materials for example MNVP and LMNS lead job/role descriptions and person specifications.

Infrastructure

Operational and logistical support

2.24 As set out in the three-year plan, MNVP leads will need support to enable them and their MNVPs to carry out their function.

A well-functioning and embedded MNVP will likely require several types of operational support, such as:

• Accounting and business management, including processing of service user expenses and budget reporting.
• Administration: day-to-day work plan monitoring, materials produced for activities and meetings, surveys, Q&A for MNVP members.
• IT equipment and software (an NHS email account will allow the MNVP lead to share documents securely and comply with NHS information governance and communication rules).
• Project management support.
• Communications, stakeholder engagement and publicity such as social media support, media support, promotional materials, branding and event organisation and support.
• HR functions, such as recruitment, safeguarding, grievance, and emotional and psychological well-being support.
• Engagement and management of volunteer service user voice representatives who form the MNVP membership.
• Research, data analysis and reporting, including collation of feedback data.
• Data protection and management, including compliance with GDPR
• Training.

2.25 There should also be procedures in place to handle grievances raised by an MNVP lead and complaints made against an MNVP lead or member.

2.26 This operational and logistical support could come from existing ICB provision or commissioned through an external provider.

The way in which ICBs provide appropriate support will depend on the system structure and local factors.

For ICBs with multiple MNVPs, much of this support can be shared across MNVPs, achieving economies of scale.

2.27 ICBs will need to make local decisions on the geographical footprint of each MNVP based on local system landscape, geography, demographics and other factors.

They may want to consider that the footprint built around a maternity unit is likely to make most sense to local women and their families, as this is the organisational unit they identify with.

This may mean more than one MNVP per trust. Women and their families are much less likely to identify with other organisations, such as an ICB or multi-hospital trust.

2.28 In any case, ICBs will need to ensure that there is also an infrastructure to enable MNVPs to participate in ICB level decision-making, as set out above.

2.29 ICBs, in partnership with maternity and neonatal stakeholders, will need to decide whether the operational and logistical functions of MNVP(s) will be provided ‘in-house’ by the ICB or if an external organisation will be commissioned to host the MNVP(s).

2.30 The 2022 Review of the funding and function of maternity voices partnerships showed that MNVPs hosted by ICBs and MNVPs hosted by third-party organisations have both advantages and disadvantages.

Which option works best for each system will be down to local determination, but due consideration of the impact, sustainability and risks of both options are important.

In systems with multiple MNVPs, the operational and engagement support can be shared across MNVPs, whether this is provided by the ICB or commissioned externally.

Workplans

2.31 In addition to the principles set out above on remuneration, effective MNVPs will have good quality workplans in place to deliver the programme of work required to fulfil their remit of listening to and representing service user voice, and the responsibilities set out in national reports, guidance and policy.

A workplan should be flexible enough to respond to the needs of the service and community as these arise and to fulfil the agreed deliverables. The workplan could also include the MNVP strategy, objectives, supporting activities and reporting requirements.

Developing MNVP workplans

2.32 In developing high quality workplans the following best practice should be considered:

1. Co-production – a good plan will be co-produced in partnership with maternal and neonatal stakeholders including the provider trust, LMNS and service user voice representatives.
2. Resourcing – ensure sufficient time and funding is committed to co-producing a high-quality workplan.
3. Information – identify and define the requirements and responsibilities of the MNVP by reviewing national, regional and local policy documents and local intelligence gained from various sources, including but not limited to:
   • MNVP engagement
   • the CQC maternity survey
   • clinical outcomes
   • quality surveillance.
4. Alignment – ensure alignment with trust, LMNS strategies, as well as the ICB five-year joint forward plan and integrated care strategy, and the national three-year plan. This involves bringing together senior stakeholders from across systems to co-produce the workplan.

2.33 It is good practice for the MNVP workplan to be reviewed and updated regularly, reflecting on the MNVP’s work and considering any outstanding and ongoing work and intelligence gathered through engagement and outreach activities.

2.34 MNVPs should seek to reach agreement with their ICB on the content and activity in their workplans.

ICBs are responsible for providing appropriate funding to deliver the workplan. This equally means that the workplan and the level of funding will need to be aligned.

2.35 Where there are disagreements on the content or activity of workplans, where possible these should be resolved at a local level using ICB policies and governance.

Given the link between listening to women and families and the safety of maternity services, as a last resort concerns may be escalated using the PQSM.

2.36 An example of the type of activities included in workplans produced by Cornwall and the Isles of Scilly LMNS are included in the supporting materials document.

Budgets, remuneration and expenses

2.37 It is the ICB’s responsibility to provide funding in line with the co-produced workplan and to support the infrastructure and operational support as well as engagement activities for MNVPs.

Effective MNVP budget setting is carried out in conjunction with maternity and neonatal stakeholders including provider trusts, LMNS and service users voice representatives.

2.38 ICBs can make funding available in several ways (and in a combination of different ways), including:

• delegating a budget to the MNVP lead to manage (where the MNVP lead is an employee)
• entering a contract with a third party to provide funding in return for specified outputs
• providing access to in-house services
• making direct payments to individuals (for the purposes of remuneration or payment of expenses).

While appropriate financial controls will always need to be in place, the MNVP will find it difficult to operate without easy access to funds to cover basic operating expenses.

2.39 When setting budgets, consideration should be given to leadership roles, operational support and member expenses.

Leadership roles and operational support are not suitable to be provided by volunteers and ICBs will need to consider this as part of their budget setting for MNVPs (bearing in mind that support functions may be delivered through existing roles in the ICB or partner organisations).

A budget template is included in the supporting materials for reference.

2.40 A sufficient budget will also be necessary for engagement activities.

ICBs may wish to consider apportioning sufficient budget from any existing budget for engaging with people and communities specifically to MNVPs. Expenses arising from engagement may include:

• Venue and simple refreshments
• Facilitation
• Translation and interpreting
• Promotion.

2.41 It is common practice to offer low-value incentives for participation in engagement activities, such as low denomination shopping vouchers.

This can be a useful tool in ensuring engagement from a broad cross-section of the local community. ICBs may want to facilitate this within the confines of locally determined rules.

2.42 In line with the commitments set out in the three-year plan, and as well as remuneration for MNVP leads, the budget should include reimbursement for all MNVP members for reasonable expenses. These may include:

• Travel expenses
• Accommodation and subsistence when required
• Childcare for when the member is participating in MNVP meetings or activities.

As part of this, ICBs will need an easy process to receive claims and make timely payments.

2.43 There should be at least one service user lead who is formally part of the LMNS board, and they should have a formal mechanism to co-ordinate feedback and co-production with all local MNVPs and service users within the system.

Publication reference number: PRN00823_i