Objective 1: Enhance maternity engagement and access in the community
Action 1
Embed the role of the South West London LMNS maternity core connectors to build relationships with community partners.
How we will measure success
Increased engagement/membership of LMNS board meetings/events.
Action 2
Work with our trusts to make sure consistent messages are shared on all our public facing websites and media to improve access to relevant information.
How we will measure success
- Standardised and easily accessible maternity information provided across the LMNS.
- Review and edit our webpages.
Action 3
Increase parental voice and participation in service development through Maternity and Neonatal Voice Partnerships (MNVP) and service user engagement.
How we will measure success
- Increased MNVP and service user engagement and participation.
- Membership of LMNS board meetings/event.
Action 4
Develop a small LMNS grants pot to encourage innovation.
How we will measure success
Use small pots of funding to run innovation pilots.
Action 5
Map out new clinical spaces in the community to support community midwives and increase access to maternity support.
How we will measure success
Identify community hubs available for midwives.
Action 6
Increase uptake of targeted and enhanced continuity of carer for women from minority ethnic backgrounds and those living in deprived areas.
How we will measure success
Ensuring continuity of care for women from minority ethnic communities and from the most deprived groups. This model of care requires appropriate staffing levels to be implemented safely.
Action 7
Implement maternal medicine networks.
How we will measure success
- Increase routine monitoring of attendances and number of new referrals into the network.
- Improved clinical outcomes and reported experience.
Action 8
Identify and offer referral to the NHS Diabetes Prevention Programme to women with a past diagnosis of gestational diabetes mellitus (GDM) who are not currently pregnant and do not currently have diabetes.
How we will measure success
- Increase in the identification of women with a past diagnosis of gestational diabetes mellitus.
- Improved clinical outcomes and reported experience.
Action 9
Ensure personalised care and support plans are available to everyone.
How we will measure success
Improved clinical outcomes and reported experience.
Action 10
Ensure equal access to information and support to perinatal pelvic health programme.
How we will measure success
- Increase in early diagnosis of perinatal pelvic health challenges.
- Increase in access to perinatal pelvic information on SWL apps.
- Improved clinical outcomes and reported experience.
Objective 2: Listen to marginalised groups and act
Action 1
Ensure marginalised groups have access to personalised care and support plans.
How we will measure success
- Percentage increase in minority ethnic women and women living in deprived areas have safer outcomes during their pregnancy.
- Percentage increase of minority ethnic women and women living in deprived areas with a personalised care plan.
- Percentage increase in minority ethnic women and women living in deprived areas using Baby Buddy app.
- Improved clinical outcomes and reported experience.
Action 2
Develop a system-wide forum to routinely hear from marginalised birthing people and their families.
How we will measure success
- More service users co-producing SWL LMNS programmes.
- Number of forums hosted.
- Number of members attending forums.
- Number of marginalised groups attending forums.
- Measure the ‘act’ through Improved clinical outcomes and reported experience.
Action 3
Recruit independent senior advocate at LMNS level who reports to both the Trusts and the LMNS Board.
How we will measure success
• Independent senior advocate recruited.
Action 4
Each trust board must identify a non-executive director with oversight of maternity services, with specific responsibility for ensuring that women and family voices across the trust are represented at board level. They must work collaboratively with their maternity safety champions.
How we will measure success
Non-executive director recruited in each trust.
Action 5
MNVP groups to actively increase representative membership – particularly minority ethnic groups and those living in areas of deprivation, including dads.
How we will measure success
Percentage increase of MNVP membership, focusing on minority ethnic backgrounds and those living areas of deprivation.
Action 6
All maternity units to ensure women and birthing people have access to an effective language translation service.
How we will measure success
- All women have easy access to translation services in a maternity setting on request or if need is identified.
- Improved clinical outcomes for people with a second language.
Action 7
Recruit Maternity Community Core Connectors to support community building and knowledge in maternity.
How we will measure success
Maternity Core Connectors recruited.
Opjective 3: Increase maternity prevention programmes across the area
Action 1
All trusts to implement Saving Babies Lives Care Bundle Version 3.
How we will measure success
- Percentage reduction in low birth weight (<2,500g for term births).
- Percentage reduction in smoking at time of delivery.
- Percentage reduction of preterm births.
Action 2
Increase take up of targeted and enhanced Continuity of Carer.
How we will measure success
- An increase of women from minority ethnic backgrounds and those living in deprived areas are prioritised and receiving continuity of carer.
- Improved clinical outcomes and reported experience.
Action 3
All Trusts to implement a smoke-free pregnancy pathway for women, birthing people and their partners.
How we will measure success
Implementation of the NHS LTP funded tobacco dependency treatment pathways in maternity by 2024/25.
Action 4
Increase access to Vitamin D.
How we will measure success
- Increase in supplementation of Vitamin D in women from minority ethnic backgrounds and those living in deprived area.
- Improved clinical outcomes and reported experience.
Action 5
Develop and Implement an LMNS infant feeding strategy and continuously improve breastfeeding rates for women living in the most deprived areas.
How we will measure success
- Increase uptake in breastfeeding initiation rates – including neonates.
- Percentage increase in breastfeeding at 6 weeks.
- Percentage increase in breastfeeding at 6 months.
Action 6
Implement the perinatal pelvic health programme across South West London.
How we will measure success
- Increase in number of women accessing perinatal pelvic health support and information.
- Improved clinical outcomes and reported experience.
Action 7
Support roll out of information on how to access the maternal mental health service (MMHS) with midwifery staff.
How we will measure success
Increase in access to mental health prevention services for women from minority ethnic backgrounds and those living in deprived areas.
Action 8
Increase uptake of Baby Buddy app.
How we will measure success
- Percentage increase uptake of Baby Buddy app.
- Increase number of service user feedback.
Action 9
Recruitment of an immunisation manager.
How we will measure success
- Immunisation manager recruited.
- Increase uptake of Flu/Pertussis jab for pregnant women .
Action 10
Improve attendance of pre-conception clinics.
How we will measure success
Increase in attendance at pre-conception clinics.
Objective 4: Review service provision for protected characteristics
Action 1
Commission a service to map diverse population data, protected characteristics and inclusion groups – such as sexual orientation or disability.
How we will measure success
- We can better identify needs of birthing people and target services towards protected characteristics groups.
- Identify groups to be included and monitored on the maternity dashboard.
- Improved clinical outcomes and reported experience.
Action 2
LMNS to have sight of each Trusts’ Public Sector Equality Duty (PSED) reporting obligations – the obligation is for every trust to undertake PSED and then publish their equality information that they have for their services and outline what their objectives are.
How we will measure success
- Identify if each trust has a PSED in place.
- Review gaps that have been identified in Trust PSED specifically on maternity population.
- Ensure the Equality Delivery System (EDS) is being used by each trust.
- EDI Trust leads and ICS trust leads to share good exemplars of practice with the other Trusts or other divisions in their Trust that need to improve.
Action 3
St George’s programme ‘Getting over the bump’ will be rolled out to other maternity units. The programme works in partnership with women coming into pregnancy with a pre-existing physical or sensory disability.
It will focus on each individual’s need to increase equal access to relevant information, support services and enable choice and control for pregnancy, birth and parenting.
How we will measure success
Roll out of the programme to all SWL maternity units.
Objective 5: Improving and learning as a system
Action 1
All SWL maternity units to engage and participate in all LMNS serious incidents meetings – send cases for system review and learning.
How we will measure success
- LMNS lessons learnt log kept up to date and monitored.
- Service changes and improvements implemented and evidenced at system level.
- Improved clinical outcomes and reported experience.
Action 2
Encourage the capture of positive events, outcomes and best practice to be shared routinely across the system for example by using GREATix (the database that captures positive events in the NHS) and improve safety by sharing and spreading excellence.
How we will measure success
- Reduction in repeat serious incidents across the system.
- Increase the number of positive events reported at system level.
- Improved clinical outcomes and reported experience.
Action 3
Ensure every trust has a patient safety specialist, specifically dedicated to maternity services.
How we will measure success
Patient safety specialist recruited.
Action 4
Ensure routine dashboard monitoring to identify thematic trends, insights and intelligence for learning/early detection of safety issues and challenges before it becomes a serious incident.
- Increased number of deep dives informed by dashboard monitoring.
- Improved clinical outcomes and reported experience.
- Regular monitoring of PMRT themes.
Action 5
Ensure LMNS has oversight of trusts CNST 10 actions for assurance Clinical Negligence Scheme for Trusts (CNST).
How we will measure success
Improved clinical outcomes and reported experience.
Action 6
Ensure service user feedback feeds into learning framework.
How we will measure success
- Reduction in repeat safety issues and challenges.
Action 7
Ensure frequent multi-disciplinary opportunities are available for professional development and support e.g. LMNS annual safety event to align with the Ockenden and Kirkup recomendations.
How we will measure success
- Number of MDT training at system level.
- Increase in number of MDT events across SWL LMNS.
Action 8
Engage with ICS peer review framework rollout.
How we will measure success
- Alignment of ICS peer review framework with maternity.
Action 9
Co-produce system multidisciplinary training on cultural competency in maternity and neonatal services.
How we will measure success
- Number of training sessions hosted.
- Number attending sessions hosted.
- Staff feedback on training sessions.
- Percentage of staff attended Cultural competency training.
- Percentage of groups of staff trained in equality and diversity.
Objective 6: Improve data collection
Action 1
Ensure coding for all ethnic minorities by all trusts which include interpreter needs – Including serious incidents cases.
How we will measure success
- Quarterly measurements of ethnicity data quality.
- Percentage of maternity and neonatal Serious Incidents relating to patient care with a valid ethnic code.
Action 2
Understand staff experience, using Workforce Race Equality Scheme (WRES) and ensure data is completed for all maternity units.
How we will measure success
- Ensure WRES themes are shared and actioned.
- Evidence of the ongoing changes.
- Staff satisfaction survey results.
Action 3
LMNS to recruit a maternity data analyst to understand population needs.
How we will measure success
- Data analyst recruited.
- Annual reviews of Maternity Health Outcomes Profile.
- Updated maternity dashboard.
Objective 7: Increase staff equity and wellbeing
Action 1
Each trust to recruit Health Inequalities Lead 0.2 WTE.
How we will measure success
Maternity Health Inequalities lead recruited in each trust.
Action 2
Co-produce system-wide multi-disciplinary training on cultural competency in maternity and neonatal services.
How we will measure success
- Number of training sessions hosted.
- Staff feedback on training sessions.
- Percentage of staff attended cultural competency training.
- Percentage groups of staff trained in equality and diversity.
Action 3
Ensure staff are well trained and supported to deliver services using evidence-based approaches and support trusts to sustainably maintain the training compliance as per national target.
How we will measure success
- Ongoing monitoring of training numbers.
- Reduction in complaints and serious incidents.
- Improved clinical outcomes and reported experience.
Action 4
Implement the Workforce Race Equality Standard (WRES) in maternity and neonatal services.
How we will measure success
Percentage of ethnic minority staff in leadership/management posts.
Action 5
Develop and implement LMNS wide surveys of staff experience using the Croydon HEARD campaign as a template.
How we will measure success
- Insight on staff experience gathered.
- Percentage uptake of staff survey.
Action 6
Ensure succession planning is implemented and employees from minority ethnic backgrounds have equal opportunities to leadership roles.
How we will measure success
- Percentage of minority ethnic staff on the leadership career ladder.
- National/regional training for minority ethnic staff on leadership.
Action 7
Ensure LMNS receives assurance that trust are carrying out wellbeing surveys.
How we will measure success
- Evidence of increased staff retention and promotion.
- Reduction in complaints.
- Improved patient experience.
Action 8
LMNS to work with each trust to develop staff roadshows to increase knowledge and raise profile of LMNS and key maternity transformation deliverables.
How we will measure success
Increase in staff knowledge of LMNS and key programmes of delivery.