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Home E Get Involved E Start Well: Ensuring the best care for pregnant women and people, babies, children, young people, and their families

Start Well: Ensuring the best care for pregnant women and people, babies, children, young people, and their families

Start Well brings together staff and patients from across the NHS in North Central London to think about how maternity, neonatal, and children and young people’s services are working.

We want to understand whether we are delivering the best services to meet the needs of people living in Barnet, Camden, Enfield, Haringey and Islington, and those from neighbouring boroughs and beyond who choose to use our services.

We have set out what we know about current NHS services and highlighted some opportunities for the future in a Case for Change document.

We would like to know if you think we have missed anything important that needs to be considered, and what is most important to you and your family, and your local community as we plan our response to the opportunities for improvement highlighted.

You can read:

Give us your views, and help the NHS deliver even better services for children, young people, pregnant women and people, and babies.

The background to Start Well

Health and care organisations in North Central London covering Barnet, Camden, Enfield, Haringey and Islington, have been working together on a long-term programme looking at children and young people’s, maternity and neonatal services, called Start Well.

Through Start Well, the NHS is asking if we are:

  • Delivering the best services to meet the needs of pregnant women and people, babies, children, young people and their families
  • Doing all we can to reduce differences in health outcomes and experience
  • Learning from the pandemic and responding to national policy and independent reviews

Start Well is specifically looking at:

  • Children and young people’s planned (elective) services in hospitals
  • Children and young people’s emergency services in hospitals
  • Maternity services
  • Neonatal care for babies who are unwell when they are born or are born early and need extra support

They are focusing on our local hospitals:

  • North Middlesex University Hospital NHS Trust
  • Royal Free London NHS Foundation Trust which covers three hospitals: Barnet Hospital, Royal Free Hospital and Chase Farm Hospital
  • University College London Hospitals NHS Foundation Trust
  • Whittington Health NHS Trust

The programme also touches on services provided by specialist providers, including Great Ormond Street Hospital for Children NHS Foundation Trust (GOSH), Royal National Orthopaedic Hospital NHS Trust (RNOH) and Moorfields Eye Hospital NHS Foundation Trust (Moorfields).

The links between the local hospitals and specialist hospitals, particularly GOSH, have been considered as part of the review.

Community, mental health services and primary care are not being reviewed as part of the Start Well programme, but the overlap between them and this programme is being carefully considered.

What patients said about services

While many receive excellent care in local hospitals, there are also areas for improvement, and some current and future challenges. We need to respond to what patients have told us.

We heard from local people, who told us their priorities:

  • Better communication between hospitals and patients
  • Better communication between individual staff members and individual patients and clearer, more accessible information
  • Personalisation and continuity of care
  • To be treated with equal respect
  • Better spaces and facilities for their care
  • Recognition of the important link between physical and mental health

The opportunities to improve care for pregnant women and people, and babies

We need to address differences in what services are provided, where they are, and the experience of those using maternity services

We understand that there are many factors influencing pregnant women and people’s needs for NHS maternity and neonatal services and we know that not all pregnant women and people have the same experience. We also know that there are differences in outcomes.

  • Black and Asian pregnant women and people have more complications in pregnancy, when compared to White pregnant women and people and their babies are more likely to need additional support in a neonatal unit after birth
  • Nearly three-quarters of pregnant women and people giving birth at the North Mid live in the 40% most deprived areas
  • The stillbirth rate in NCL varies between boroughs, with Haringey and Enfield having the highest rates in NCL
  • The number of pregnant women and people accessing perinatal mental health care in all boroughs is below national targets. We need to go further to support those with mental health conditions before, during and after pregnancy.

We need to focus on supporting those people that use maternity services so that they are able to access the right services. This means considering the diversity of our population when planning services.

We need to make better use of the range of maternity services we have across NCL to support patients’ choices

Supporting women and pregnant people to make informed choices about their birth is crucial.

Currently pregnant women and people in NCL are more likely to choose, or be advised, to give birth in an obstetric (specialist doctor) led unit. This means that the use of obstetric-led units is very high, while on average, midwife-led units were used to around only 30% of their possible capacity.

We need to understand the reasons for this difference. It may be that pregnancies are more complex and require this more specialist care. However, it is also possible we need to support pregnant women and people to choose the full range of birthing options that are appropriate and safe for them.

Overall, we need to understand if we have the right balance of services to meet the needs of all the pregnant women and people, from NCL and beyond, who choose to give birth at our hospitals.

We need to ensure sufficient neonatal care in the right places

The NHS has different kinds of neonatal unit to look after babies who are born prematurely or are unwell.

View the different kinds of neonatal units.

All hospitals in NCL that provide obstetric (specialist-doctor) led maternity care have a neonatal unit, however the use of these varies:

  • UCLH and GOSH care for the most premature and unwell babies. They are often full, which means that babies who need the highest level of care are sometimes transferred further away from home.
  • The Royal Free Hospital’s neonatal unit is only able to provide the least specialist level of neonatal care. The use of this unit is much lower and over half of its cots are not used on any given day. Special arrangements are in place to help staff maintain their skills in looking after unwell babies. There is a question about whether the unit can continue to run safely in its current form, and the NHS needs to think about what happens in the future.

Not having access to the right care at the right time can be stressful and distressing for families and staff. We need to properly understand and plan for the right amount and type of neonatal care to meet the needs of everyone.

We need to support families with unwell babies to be cared for at home

Neonatal outreach teams offer care to babies that have been born early or are unwell at home, rather than in hospital. This keeps families together in an environment where they feel safe and comfortable, while ensuring that babies get the level of care that they need. However, the same services aren’t available everywhere.

We need to ensure all babies and their families can access the same services, no matter where they live.

We need to provide everyone with the best hospital environment, wherever they live

Hospital facilities should provide privacy, preferably labour rooms with en-suite bathrooms and space for a birth partner to join delivery when possible. Some hospitals have modern facilities that offer all of this; however the quality of some of the buildings, most notably at Whittington Health, does not currently meet modern standards.

The opportunities to improve care for children and young people

We need to address the increasing demand for children and young people’s emergency services

Emergency Departments (EDs) provide emergency care for over 160,000 children and young people a year and this is increasing. However, use of these services is not evenly distributed across hospitals.

Barnet Hospital and North Mid have large numbers of attendances and serve large catchment areas. In the south of NCL, there are three hospitals – ULCH, Whittington Health and the Royal Free Hospital – providing emergency care that are close to each other. The total number of paediatric ED attendances at North Mid is the highest in London and is greater than UCLH and the Royal Free Hospital combined.

We know that an ED isn’t always the best place for some children and young people to receive their care and there are a large proportion of cases that could have been treated in the community or at a GP practice.

With use increasing, we need to think about how best to support our emergency departments to ensure everyone gets the care they need and to look at opportunities to provide alternative ways of accessing emergency care.

We need to improve care for children and young people with long-term conditions

Some children and young people with long-term conditions do not get enough support to manage their health, leading to unplanned time in hospital.

Children and young people with asthma living in the most deprived areas of NCL were twice as likely to be admitted to hospital than those with asthma living in the least deprived areas of NCL.

We need to consider why this is, and ensure the resources are available in the right places so we can support these children and young people better.

We need to provide high-quality emergency surgery for children and young people and reduce waiting times for planned surgery

If a child or young person needs surgery, whether this is planned or as the result of an emergency, we need the right services in place and to make sure that no one waits too long. We currently have challenges in delivering this.

1 in 5 children and young people who needed to be transfered to different hospital for emergency surgery were moved outside NCL.

Most children requiring a transfer went to GOSH, but some were transferred outside of NCL. While some of these children will require specialist care, some could have been seen in local hospitals if a team with the right surgical or anaesthetic skills had been available. Arranging transfers for patients is time consuming for clinical staff and worrying for the child or young person and their family, and it may also impact on the outcome of the surgery. There is a need to look at this variation.

There are around 4,300 children and young people in NCL waiting for a planned operation and the waiting list is growing. The current situation doesn’t meet NHS targets and has a significant impact on the wellbeing of the children, young people and families waiting.

Over 330 children and young people have been waiting over a year for surgery and 1,600 over 18 weeks. Some types of surgery, such as dentistry, have longer waits than others. Some hospitals have very small services for some specialties and some struggle to plan operations for children and young people alongside emergency care. We know there are joint working arrangements across teams in different hospitals, which we can build upon in the future.

More needs to be done across our hospitals to address long waits and skills gaps.

We need to improve the transition from children’s NHS services to adult services

For children and young people living with long-term ill health, the transition from adolescent to adult services is an important step, however this is currently managed in an inconsistent way. There is an opportunity to review and improve this and consider how children and adult services could work better with families.

We need to address the staffing challenges in midwifery, children’s nursing and other health professionals

There are currently high numbers of staff vacancies in midwifery, children’s nursing and other health professionals that care for babies, children and young people. The hard work of current staff and support across hospitals helps to address gaps but we know that there is further work to do.

  • The number of midwives staffing maternity units can have a significant impact on the quality and safety of maternity services, but we know that nationally, we don’t have enough trained midwives.
  • An additional 26 neonatal nursing posts are needed across all NCL units and there are also significant gaps in allied health professional roles to support babies, such as speech and language therapists to help identify and support babies at risk of feeding difficulties
  • Vacancy rates are particularly high in paediatric nursing, with rates ranging from 13% to 36% across our hospitals
  • To address gaps, staff work under pressure and this is leading to staff burnout

There are staffing challenges across the NHS, but there is also an opportunity for organisations across NCL to work together to develop innovative solutions.

Give us your feedback

We want to receive the views of as many patients, public, staff and partners as possible on the opportunities identified to inform what happens next. This includes residents of Barnet, Camden, Enfield, Haringey, Islington and neighbouring areas who might use hospital services in North Central London. We are particularly interested in hearing from anyone who has current or recent experience of these services, or anyone who might need these services in future, and their families and carers.

Other ways to feedback:

  • request a printed version of our questionnaire using the contact details below
  • Write to FREEPOST NCL NHS (no need for a stamp or postcode)
  • Invite the Start Well team to speak to your group (email nclccg.startwell@nhs.net)
  • Phone 020 3816 3776.

    The opportunity to give feedback runs from 4 July to 9 September 2022

    Please get in touch if you need additional help to participate. Our patient leaflet is available in large print, Easy Read or Braille on request. We can also offer translations and additional support if English is not your first language.

    You can phone us on 020 3816 3776 to give feedback verbally.