Expo is the most significant annual health and social care event in the calendar, uniting more NHS and care leaders, commissioners, clinicians, voluntary sector partners, innovators and media than any other health and care event. Expo 15 returned to Manchester and was hosted once again by NHS England. Around 5000 people a day from health and care, the voluntary sector, local government, and industry joined together at Manchester Central Convention Centre for two packed days of speakers, workshops, exhibitions and professional development. This year, Expo was more relevant and engaging than ever before, happening within the first 100 days of the new Government, and almost 12 months after the publication of the NHS Five Year Forward View. It was also a great opportunity to check on and learn from the progress of Greater Manchester as the area prepares to take over a £6 billion devolved health and social care budget, pledging to integrate hospital, community, primary and social care and vastly improve health and well-being. More information is available online: www.expo.nhs.uk

1. Saving babies’ lives: a plan for
implementation to reduce stillbirth and
early neonatal death
Dr Dimitri Varsamis - Programme Manager, Acute Care Clinical
Policy and Strategy Unit, Medical Directorate, NHS England
Professor Donald Peebles - Hon Consultant in Maternal/Fetal
Medicine UCLH, Head UCL Research Department of Maternal and
Fetal Medicine, Obstetric Lead for London Strategic Clinical
Network
Heidi Eldridge - Parent and Chairman, Mama Academy

2. Overview
• The case for change
• Approach of one SCN: London
• The national clinical policy approach
• The view from the third sector

3. Stillbirth rates - LONDON and ENGLAND
2006-2013, 3yr moving average
4.60
4.80
5.00
5.20
5.40
5.60
5.80
6.00
LONDON 5.59 5.59 5.61 5.54
ENGLAND 5.14 5.20 5.04 4.90
08-10 09-11 10-12 11-13

4. Birmingham & Black Country stillbirths 1997-2006
by RECODE classification; n=2047
Congenital Anomalies
17.4%
Fetal Grow th Restriction
42.9%
Placenta 9.2%
Intrapartum Asphyxia
2.9%
Misc. 2.9%
Unclassified
16.6%
Infection 2.1%
Umbilical cord 3.5%
Mother 2.5%

5. Stillbirth rates in pregnancies with and without antenatal
detection of fetal growth restriction (FGR)
Stillbirth Rate and Fetal Growth Restriction
0
2
4
6
8
10
12
14
16
18
20
SB rat e / 1000 4.2 2.4 16.7 9.7 19.8
A ll No FGR FGR
FGR,
det ect ed
FGR, not
det ect ed
% of all births 86% 14% 4 % 10%
280 days
270 days
Gestational age at
birth, of cases without
vs. those with
A/N detection:
 Pregnancies with FGR have 7 fold higher risk of stillbirth
 Undetected FGR increases the stillbirth risk even further
 Detection results on average in delivery only 10 days earlier, and
mostly at term
BMJ 2013 http://www.bmj.com/content/346/bmj.f108

6. Antenataldetection of SGA or IUGR
Hepburn & Rosenberg 1986 26 %
Backe & Nakling 1993 14 %
Kean & Liu 1996 16 %
Birmingham – 2007 baseline 18 %
Most cases not recognised antenatally
Current methods include SFH measurement in “low risk
populations” and ultrasound assessment in “high risk”

7. • standardised fundal height measurement
• plotting on customised charts
• protocols and referral pathways
• serial scans for high risk pregnancy
Accreditation workshops commenced 2008/9
‘increased risk’
‘low risk’

8. http://bmjopen.bmj.com/content/3/12/e003942.full Dec 2013

9. Aim: to improve the detection of fetal growth restrictionin London
through the use of customised growth assessment and protocols.

10. Insufficient Evidence
• Improving on existing interventions: screening for FGR
already involves SFH measurement in “low risk” and
ultrasound in “high risk”
• There is pragmatic evidence cf BMJ paper
• Established a cluster randomised trial in London (12 units)
• All other units are implementing

11. You must be joking – a national
policy based on tape measures?
• Ultrasound for all in third trimester?
• Customisation – is this appropriate?
• Better screening for high risk?
Standardise and optimise existing interventions and
make antenatal detection of FGR an auditable
outcome. Strategy can be adapted as further
evidence becomes available

12. Intrapartum stillbirths
• London wide survey Serious Incident reports relating to
intrapartum stillbirths
• 70% related to failure to recognise abnormal fetal heart rate
monitoring or failure to escalate
• Further survey established that majority units train their staff to
perform fetal monitoring but <50% ask them to demonstrate
competence
• Toolkit to define standard that no staff should work in a birth
setting without evidence of competence

14. Saving Babies’ Lives
• Why are we doing this
• What we’ve achieved so far
• Care bundle approach, and elements and
interventions
• What’s happening now
• What will be done next and over the coming year

15. Saving Babies’ Lives - care bundle
for reducing stillbirth and early
neonatal death
Stillbirths in England are among the highest in Europe.
NHS England, together with many maternity and neonatal
care stakeholders, has been working for a year on the
development of an approach to significantly reduce these.
The programme - or ‘care bundle’ - brings together
existing best practice developed by organisations such as
NICE and royal colleges into easy-to-use guidance for
midwives and obstetricians.

16. Why are we doing this?
• Stillbirth rates in England remain among the worst of high
income countries / Europe and only small improvement in
20 years.
• Mandate and NHS Outcomes Framework: Reducing
deaths in babies and young children
(1.6.ii Neonatal mortality and stillbirths)
• Stakeholder meeting, March 2014: stillbirth reduction
identified as a priority.
• “Care bundle” approach suggested as effective means to
drive improvement.

17. Care bundle
Care bundle:
A group of interventions (or elements), usually 3-5, which focus on a
specific disease process or patient group, that when implemented
together, deliver better outcomes than if implemented separately.
(Institute for Healthcare Improvement)
Elements ought to be:
• Evidence based/widely recognisedas good practice
• Straightforward to implement
• Part of day to day practice
• All the interventions are necessary. If you removed one – the
chance of success not as high

18. What we’ve achieved so far
• Strong stakeholder engagement and consensus building
to determine that this is the right approach
• Developed the care bundle: inclusive development of
care bundle in draft, on paper, through four multi-
organisationaltask and finish groups
• Engagement with 12 Strategic Clinical Networks in
England to spread message about the bundle and
promote interest
• Around 50 per cent of providers that responded are keen
to be involved and some to take part in test and trial

19. Partial list of stakeholders
Child & Maternal Health
Intelligence Network, Public
HealthEngland (PHE)
Strategic Clinical Networks
(SCN)
Perinatal Institute
Tobacco Control Team,PHE
Sands (Stillbirth and Neonatal
Deaths Charity)
Leeds TeachingHospitals
Maternity and StartingWell
Branch,Department of Health
Bliss
Manchester Academic Health
Science Centre (MAHSC)
Royal College ofMidwives
(RCM)
MAMA Academy
Healthcare Improvement
Scotland
Royal College ofObstetricians
and Gynaecology (RCOG)
Tommy’s
British Maternal Fetal
Medicine Society
Healthand Social Care
InformationCentre (HSCIC)
Count the Kicks

20. Proposed elements
Smoking
cessation
Reduced fetal
movement
Identification
and surveillance
of fetal growth
restriction
Fetal
monitoring
during labour

21. Smoking Cessation
Element
Reducing smoking in pregnancy by carryingout Carbon Monoxide (CO) test at
antenatalbooking appointment to identify smokers (or those exposed to tobacco
smoke) and referring to stop smoking service/specialistas appropriate
Intervention
Carbon monoxide (CO) testing of all pregnantwomen at antenatalbooking
appointmentand referral, as appropriate,to a stop smoking service/specialist,based
on an opt out system.Referral pathwaymust include feedback and follow up
processes.

22. Fetal Growth Restriction
Element
Identificationand surveillance of pregnancies with fetal growth restriction
Interventions
1. Use of antenatalcustomisedgrowthcharts(symphysis fundal height ) for all
pregnantwomen by clinicians who have gained competence in their use
2. Use of supplied algorithmto aid decision making on classificationof risk, and
correspondingscreening and surveillance of all pregnanciesaccordingto their
risk
3. Ongoing audit and reporting of Small for GestationalAge (SGA) ratesand
antenataldetectionrates
4. Ongoing case-noteaudit of selected cases not detected antenatally,to identify
barriers

23. Reduce Fetal Movement
Element
Raising awarenessamongst pregnantwomen of the importanceof detectingand
reporting reduced fetal movement (RFM),and ensuring providershave protocolsin
place, based on best available evidence, to manage care for women who report RFM.
Interventions
1. Informationand advice leaflet on reduced fetal movement (RFM),based on current
evidence, best practiceand clinical guidelines, to be provided to all pregnantwomen by,
at the latest,the 24th week of pregnancy and RFMdiscussed at every subsequent
contact.
2. Use provided checklist to manage care of pregnantwomen who report reduced fetal
movement, in line with RCOG Green-topGuideline 57

24. Fetal monitoring during labour
Element
Effective fetal monitoringduring labour
Interventions
1. All staffwho care for women in labour are required to undertake an annual
trainingand competency assessmenton cardiotocograph (CTG)interpretationand
use of auscultation.Nomember of staffshould care for women in a birth setting
without evidence of training and competence within the last year.
2. Buddy system in place for review of cardiotocograph(CTG)interpretation, with a
protocolfor escalation if concernsare raised. All staffto be trained in the review
systemand escalation protocol.

25. What’s happening now?
• Providers expressing their interest in testing / early
implementing the care bundle and starting to
consider how to turn into reality
• Developing an implementation toolkit
• Working group on data to tackle data and payment
issues
• Formal evaluation being devised

26. What will be done next?
• At high-level: test the care bundle, refine, roll-
out
• Roll-out likely to be during 2016-17
• Publish the implementation toolkit in late 2015
• Procure external formal evaluation and see it
through
• Data group and wider data and information system
to devise solutions to data issues and inform work
to develop financial tools e.g. Best Practice Tariff

27. Data (and Best Practice Tariff)
Multi-organisational group set up to tackle thorny issue of data for the care
bundle
• Identify data sources that demonstrate providers are complying with the
requirements of the bundle
• Identify key activities within the bundle that are required to have associated
electronic data collection
• Influence maternity dataset to include data lines relevant to bundle
• Consider local incentives e.g. CQUINs for data reporting
• Ultimately, key function of Data and BPT group to develop a BPT for the
care bundle to incentivise compliance
• Four to six key activities within the bundle to be identified for inclusion in
BPT – must reflect element purpose
• Work with Pricing Team to ensure alignment with Maternity Pathway
Payment System

28. Communications and engagement
• Vital to continue strong engagement with sector: regular
stakeholder events
• Communications plan to ensure strong awareness of
care bundle using the most appropriate channels
• We need to bring in the NHS England Regions closer, inc
Medical and Nursing Directors
• Also: AHSNs, local PHE teams

30. How it all started

31. Aidan

32. Tobiah & Tilly

33. www.mamaacademy.org.uk

34. For Midwives

35. Made to Measure

36. Wellbeing Wallets

38. Thank you!
• Dr Dimitri Varsamis - Programme Manager, Acute Care Clinical Policy and
Strategy Unit, Medical Directorate, NHS England
• ProfessorDonald Peebles - University College London Hospital
• Heidi Eldridge - Parent and Chairman, Mama Academy