Maternity and Gynaecology

Review antenatal care ensuring schedules as outlined in NICE guidance are followed. Follow the Saving Babies' Lives Care Bundle 2 as outlined in the NHS Long Term Plan. a) For uncomplicated pregnancies, trusts to follow NICE guidance CG62 Antenatal care for uncomplicated pregnancies, as a minimum. b) Trusts to follow NICE guidance NG121, Intrapartum care for women with existing medical conditions or obstetric complications and their babies, as applicable. c) Trusts, CCGs and NHS England and NHS Improvement to work with royal colleges and professional bodies to address care inequalities, such as racial and geographical inequalities, and complex social factors, and develop strategies to engage the at-risk groups identified in their region.

Review and act upon comprehensive maternity patient experience data. a) All CCGs to have a Maternity Voices Partnership (MVP) and to actively seek to capture patient views from the whole of the local population, exploring relevant methods to expand participation in patient surveys and increase response rates from under-represented groups. b) Trusts to promote greater use of the Friends and Family Test. c) Trusts to meet national mean (2019/20) of patient experience response rate, then pursue top decile of performance. d) Trusts and CCGs to monitor national patient experience data through NPEU and CQC reporting and act upon published findings.

Strive towards healthy BMI rates and smoking rates in line with top decile of performance. a) Integrated care systems (ICS) or other local partners to review uptake of smoking cessation programmes and identify barriers to participation and action accordingly. b) Integrated care systems (ICS) or other local partners to encourage use of obesity services for women of childbearing age.

Improve recording of data about key aspects of maternity care, including outcome data for mothers and babies. For example, spontaneous birth, caesarean section, assisted birth. a) Trusts to improve data capture, such as local audit, that can then be used to inform and optimise: i. Rates of caesarean section and maximise use of Robson classification. ii. Mode of birth in line with evidence-based best practice. iii. Rates of babies born at term who are small for gestational age, as defined in Saving Babies Lives Care Bundle volume 2. iv. Rate of induction, including clinical reasoning. b) Local Maternity Systems (LMS) to actively monitor 12 month rolling average rate of serious incidents and referrals to HSIB in each hospital.

Increase focus on reducing the rate of obstetric anal sphincter injury (OASI) so that all trusts achieve OASI levels similar to those at the top decile of trusts. a) All trusts to implement an OASI care bundle and improve the safety of episiotomy when indicated. b) All trusts to audit the effectiveness of the implemented/established OASI care bundle.

Treat gynaecology patients in the most appropriate setting for their condition. a) Trusts to re-examine outpatient pathways with a view to maximising use of Advice and Guidance and virtual clinics, cutting unnecessary appointments and introducing patient-initiated follow-up. b) RCOG to provide advice, based on NICE guidance, of which diagnostics are appropriate to be carried out or commissioned by GPs prior to referral to secondary or specialist care, to increase opportunities to discharge at first appointment. c) Trusts to work with local partners to identify where patient-initiated follow-up would be feasible and put in place necessary structures to move to a patient-initiated follow-up model. d) CCGs to increase availability and use of intermediate care settings for conservative treatment (particularly physiotherapy) to allow hospital gynaecology departments to focus more on surgery. e) CCGs to commission CASH services to conduct intrauterine device insertion for heavy menstrual bleeding in relevant cases. f) Trusts to examine opportunities for digitally-enabled care, particularly for conservative treatment and to support self-management.

Expand role of nurses and other members of the wider gynaecology team to enable them to work at the top of their licence. a) Trusts to train and support nurses, physiotherapists, sonographers and other members of the team to conduct diagnostic and therapeutic gynaecological procedures (and in particular, endoscopy) to increase provider capacity.

Ensure that benign hysterectomy procedures are only offered when clinically indicated, as per NICE guidelines and Evidence-Based Interventions (EBI) programme statutory guidance. a) Providers and commissioners to review local practice and criteria for offering benign hysterectomy against NG88 Heavy menstrual bleeding: assessment and management and EBI statutory guidance. b) Providers to adopt a local review process to audit all benign hysterectomies.

Increase use of appropriate setting for surgery, with a shift to day case and/or outpatient procedures such as hysteroscopy, endometrial ablation, treatment of Bartholin's abscess, vaginal prolapse repairs and cystoscopy. a) Trusts to review metrics against national performance for day surgery and/or outpatient procedures via Model Health System. b) (New action) Trusts to ensure that all patients undergoing day case and outpatient procedures are given clear and accurate information to enable them to make informed decisions about their preferred treatment setting and pain control. c) Trusts to ensure sufficient multidisciplinary training is provided to all staff involved in the delivery of day surgery and/or outpatient procedures. d) GIRFT to discuss with NHS England the feasibility of using alternative ways to continue to incentivise change through methods of payment once block contracts are reviewed. e) Trusts/ICBs to review availability of appropriate recovery and analgesia facilities to enable and support outpatient and day case surgery.

Ensure that there is adequate expertise and availability for day case hysterectomies when clinically indicated. a) Training providers and royal colleges to include identifying suitable candidates for day case hysterectomy, and procedures for day surgery, as part of their curricula. b) GIRFT to work with trusts to enable and facilitate the delivery of day case hysterectomy where appropriate, identifying and addressing any barriers.

Following the introduction of the Medical Devices Information System, consider introducing national registries with mandatory reporting for other gynaecological procedures. a) Existing registry owners to work together, supported by GIRFT, to agree a joined-up approach to the recording of relevant data.

Consider including PROMs for gynaecology surgery in the national PROMS programme or other established national audit. a) Review existing PROMs to identify those that could be included in the national PROMS programme or other established audit. Identify any gaps and establish follow-up outcome measures at 12 months initially and then to develop further. b) Consider including PROMS identified as a result of action 12A above in the national PROMS programme or other established national audit. c) Collaborate with the wider multi-disciplinary team to develop new PROMs where gaps were identified as a result of action 12A. d) Establish and implement Patient Reported Experience Measures (PREMs) for feedback, initially at 12 months and then to develop further.

Include surgeon-specific data reported under the National Consultant Information Programme (NCIP) as part of every surgeon's appraisal. a) Individual clinicians to reflect on surgical data, including outcomes, as part of their annual appraisal. b) Department heads and clinical directors to monitor procedure-level data reported under NCIP to help identify departmental development and procurement needs, inform recruitment strategies and address local anomalies. c) Clinical directors and individual surgeons to work together to identify where individuals have insufficient recent experience, as defined by relevant professional bodies, to perform specific procedures.

Continue to support the development of surgical outcome metrics. a) Continue to develop metrics for use by surgeons and departments as part of the National Consultant Information Programme (NCIP). Use data that is routinely collected. b) Identify any further metrics needed that are not covered by existing audits. Consider developing such metrics.

Enable improved procurement of devices and consumables through cost and pricing transparency, aggregation and consolidation, and by sharing best practice. a) GIRFT to use sources of procurement data, such as the NHS Spend Comparison Service and relevant clinical data, to identify optimum value for money procurement choices, considering both outcomes and cost/price. b) GIRFT to identify opportunities for improved value for money, including the development of benchmarks and specifications. Identify best practice and procurement excellence, that lead to the most favourable procurement outcomes. c) Trusts, ICSs and GIRFT to use the new Category Towers to benchmark and evaluate products and seek to rationalise and aggregate demand with other trusts to secure lower prices and supply chain costs.

Continue to support trusts in achieving the Maternity Incentive Scheme's (MIS) safety actions. a) All trusts to familiarise themselves with the new MIS conditions and location of supporting materials e.g. MIS webinars available on NHS Resolution's website. b) Trusts to reinforce duty of candour and provide support for staff and families during and post investigation of incidents.

Reduce litigation costs by application of the GIRFT Programme's five-point plan. a) Clinicians and trust management to assess their benchmarked position compared to the national average when reviewing the estimated litigation cost per activity. Trusts will have received an updated version of this for obstetrics and gynaecology in the GIRFT and NHS Resolution 'Litigation Data Pack'. b) Clinicians and trust management to discuss with the legal department or claims handler the claims submitted to NHS Resolution included in the data set to confirm correct coding to that department. Inform NHS Resolution of any claims which are not coded correctly to the appropriate specialty via CNSTHelpline@resolution.nhs.uk c) Once claims have been verified, clinicians and trust management to further review claims in detail including expert witness statements, panel firm reports and counsel advice as well as medical records to determine where patient care or documentation could be improved. If the legal department or claims handler needs additional assistance with this, each trust's NHS Resolution panel firm should be able to provide support. d) Claims should be triangulated with learning themes from complaints, inquests and serious incidents (SI) and where a claim has not already been reviewed as an SI we would recommend that this is carried out to ensure no opportunity for learning is missed. The findings from this learning should be shared at morbidity and mortality meetings or other departmental/directorate meetings for all frontline clinical staff in a structured format. e) Where trusts are outside the top quartile of trusts for litigation costs per activity GIRFT will be asking national clinical leads and regional team directors to follow up and support trusts in the steps taken to learn from claims. They will also be able to share with trusts examples of good practice where it would be of benefit.