CCG Improvement and Assessment Framework – Maternity

The CCG improvement and assessment framework 2016-17 (CCG IAF) baseline maternity assessment provides a perspective on the effectiveness of commissioning of maternity services, enabling CCGs, local health systems and communities to assess their own progress, thereby assisting improvement. It also allows NHS England to target the support needed to assist CCGs and local maternity systems to improve.

The 2016-17 baseline maternity assessment has been designed to align with a number of the key themes from Better Births, the report of the National Maternity Review, published in February 2016. Four indicators have been selected which provide a broad representation of the various aspects of the maternity pathway:

  • stillbirth and neonatal mortality
  • maternal smoking at time of delivery
  • experience
  • choice

This assessment is intended to provide an initial baseline, a snapshot of how CCGs are performing in the areas measured by the indicators. However, it is important to note the assessment is limited by the small number of metrics selected and is not intended to provide an overall picture of the quality of maternity services within the CCG area.

In future years, a more comprehensive assessment will be undertaken, drawing on wider measures and qualitative information, assessed by an independent panel of experts with the ability to examine what is going on behind the data.

Better Births outlined a vision for maternity services to become safer, more personalised, kinder, professional and more family-friendly. The Maternity Transformation Programme will support local transformation, through local maternity systems and the Maternity Clinical Networks.   The CCG IAF will become one of the tools to support and challenge local implementation, and be a mechanism for monitoring progress. This assessment is intended to help identify where CCGs might be able to learn from each other and where support might be needed, and in turn drive improvements.

A deeper and broader understanding of maternity services locally will be gained through the development of Sustainability and Transformation Plans (STPs), the maternity component of which will align with the vision of Better Births.  Better Births recommended that commissioners and providers work together across areas as local maternity systems across footprints of half to one and a half million.  It is anticipated these will align with STP footprints in the vast majority of cases, notwithstanding that some have population sizes outside this range.

The stillbirth and neonatal mortality indicator will help to gauge the success of CCG activities aimed at reducing neonatal mortality and still birth rates. This indicator currently uses ONS data and is unadjusted. The data used for this year’s assessment is from 2014.  It is recognised that using more recent data will make this indicator significantly more useful for CCGs; NHS England will therefore continue to develop the data source and methodology for next year’s assessment to look for opportunities to make further improvements.

CCGs should use this indicator alongside information available locally and from other national sources to better understand the causes of mortality in their local populations and focus their activities towards reducing the rate. A high mortality rate warrants investigation as it may reflect shortcomings in the quality of care. However, mortality rates may be influenced by factors other than the quality of care, such as: random year on year variation; the proportion of women with high risk pregnancies giving birth to babies; and the proportion of mothers who choose to carry babies affected by severe congenital anomalies to term. Caution is therefore required when interpreting mortality rates in isolation from other sources of information.

The maternal smoking (at time of delivery) indicator will contribute to measuring the success of interventions to reduce smoking in pregnancy, as recommended by NICE guidance (PH26). Performance in this indicator will reflect the effectiveness of ‘stop smoking’ services and working relationships with local authorities through the Health and Wellbeing Boards. This indicator also relates to the effective screening by maternity services of pregnant women throughout their pregnancy through Carbon Monoxide (CO) monitoring, as required by the Saving Babies’ Lives care bundle.

The use of this indicator in the CCG IAF is intended to shine a light and encourage action to reduce smoking in pregnancy as there is strong evidence that do so reduces the likelihood of stillbirth. It also impacts positively on many other smoking-related pregnancy complications such as premature birth, miscarriage, low birth-weight and Sudden Infant Death Syndrome (SIDS). Whether or not a woman smokes during her pregnancy has a far reaching impact on the health of the child throughout his or her life.

The Experience indicator measures women’s experiences of maternity services based on answers to the Care Quality Commission (CQC) 2015 National Maternity Services Survey.

The Choice indicator uses the same CQC survey to specifically look at the choices offered to users of maternity services.  Each of these two indicators are composite indicators, calculated as an average of scores from six questions from the survey reflecting several points across the care pathway (antenatal, intrapartum and postnatal). The experience and choice indicators have been adjusted for age and for parity (the number of times a woman has given birth).

Methodology for indicator ratings and overall banding

A score of A, B or C was applied for the individual metrics, depending on whether a CCG’s performance was above the standard of the majority (A), in line with the majority (B), or below the standard of the majority (C). All four of the maternity indicators were rated into A, B or C using a funnel plot method. A 90 percent confidence level means that there is only a 10 percent chance that a CCG might be an outlier by chance alone.

To reach the overall rating for maternity, an algorithm is used, which takes into consideration how many As, Bs and Cs a CCG has. If a CCG has four Bs, it comes out overall as “needs improvement”. If a CCG has more than two Cs it “has the greatest need for improvement”. “Top performing” CCGs have a minimum of three As and a B, and to be “performing well”, a CCG can have a maximum of one C, as long as they have a minimum of two As.

Support to CCGs from NHS England

The National Maternity Policy Team at NHS England is developing a package of support for CCGs to improve maternity outcomes.

To support local transformation, NHS England will:

  • Provide support for the formation of local maternity systems, via the Maternity Clinical Networks (£1m of funding provided) and NHS England regional offices, helping to identify key local maternity actors and build relationships between commissioners, providers and other key organisations that will form the local maternity system
  • Hold roadshows in each of the Maternity Clinical Network areas to disseminate the vision of Better Births and the activities of the Maternity Transformation Programme in support of the transformation of local maternity services. These started in September and will continue through until November 2016.
  • Operate an Early adopters scheme to help those local health economies who want to move more quickly with implementing Better Births and extract key insights and learning for sharing with all
  • Support the STP process and to help STP footprints incorporate maternity transformation into their plans – an aide-memoire has been published, to help STP footprints understand the key issues in maternity
  • Produce guidance on
    • establishing community hubs
    • moving towards continuity of carer models, with an associated support package
    • operating local maternity systems, including the role of shared governance and transfer protocols.
    • undertaking the booking in conversations and producing personalised care plans.
    • commissioning for outcomes in maternity
  • Support local action to reduce the number of stillbirths and neonatal deaths by publishing and promoting the Saving Babies’ Lives care bundle (through a digital toolkit, support through the Clinical Networks and developing incentive payments)
  • Maternity Safety Quality Improvement Programme:  Maternity units will work together with Clinical Networks and patient safety collaboratives and will have access to national and international experts who will support them to actively develop and continuously review concrete plans to implement best safety practice in their units
  • Support maternity choice and personalisation pioneer sites to develop and implement ways of improving the offer, take up and operation of choice and personalisation in maternity services, before national roll-out and dissemination of products, processes and lessons learned
  • Support multi-professionalism through working with Health Education England on the rollout of multi-professional training
  • Design a nationally recommended set of quality indicators for local use in monitoring service quality, including patient reported experience measures
  • Develop a new digital tool to help women make choices, manage their own care and obtain peer support
  • Work with NHS Improvement to review the payment system