Government Response to HSC Recommendations

Below is the Government response to the report from the Health Select Committee following on from our petition.

Government Response to

Report of the Health Committee on

Petition 2008/23 of Jennifer Maree Hooper

Presented to the House of Representatives

In accordance with Standing Order 248

Government Response to the Report of the Health Committee

on Petition 2008/23 of Jennifer Maree Hooper

Introduction

1. The Government welcomes the Health Committee’s report, entitled “Petition 2008/23 of Jennifer Maree Hooper” (the report). The report is a response to the 2009 petition of Jennifer Maree Hooper (the petition), which requested that the House note “that 826 people have signed a petition asking the House of Representatives to make any and all necessary changes to New Zealand’s maternity system to increase safety and protection for all mothers and babies”.

2. In its consideration of the petition, the Health Committee drew on relevant report findings from independent ministerial advisory committees (the Perinatal Maternal Mortality Review Committee and the National Health Committee), as well as international trends and recent changes to the maternity system. It received comment on the petitioner’s recommendations from the Ministry of Health, the New Zealand College of Midwives, the New Zealand College of Obstetricians and Gynaecologists, Dr Dawn Elder, and Professor Cindy Farquhar. Dr Elder and Professor Farquhar are members of the Perinatal and Maternal Mortality Review Committee (PMMRC).

3. The Health Committee delivered 14 recommendations in its report, some of which reflect the petitioner’s recommendations. The Health Committee recommendations are on the following topics:

a. continued development of a collaborative, non-fragmented model of maternity care

(recommendation 1)

b. evidence-informed best practice guidelines to guide clinical practice and support for

families following a bereavement (recommendation 1,3)

c. improved maternity data for monitoring and quality improvement (recommendation 2)

d. referrals and sharing of information between General Practitioners, Lead Maternity

Carers and Well Child providers (recommendations 4,5,6)

e. consumer satisfaction surveys, including of parents whose babies suffered serious

adverse events or died before or during birth (recommendations 7,8)

f. compulsory monitoring, supervision and education updates for newly graduated

midwifery and medical practitioners providing maternity care (recommendation 9)

g. coordinated support for families affected by adverse events (recommendation 10).

4. The Health Committee also recommended that the Government’s existing Maternity Quality Initiative continue to be “vigorously implemented” (recommendation 11) and that the Government take note of previous reviews and reports on the maternity system (recommendations 12,13,14).

5. The Government has carefully considered the Health Committee’s report and responds to it in accordance with Standing Order 248.

6. The Government supports the Health Committee’s intention of identifying where

improvements can be made in the current maternity system. Many of the Health Committee’s recommendations are consistent with current priorities in the maternity sector. Some of the recommendations are already met, or are currently being addressed as part of the Government’s Maternity Quality Initiative and other national initiatives.

7. The Maternity Quality Initiative was developed following significant work with the maternity sector from 2007-2009. During 2007 and 2008, a Maternity Services Strategic Advisory Group, the Ministry of Health and DHBs worked together to develop a strategic vision for the next five to ten years (known as the draft Maternity Action Plan). The draft Maternity Action Plan was released for consultation in June 2009, generating considerable interest and a range of views from the maternity sector, consumers and non-government organisations. The four key actions from the plan that received consistent support from stakeholders were:

a. developing a national quality and safety programme

b. updating guidelines for referrals between Lead Maternity Carers and obstetricians and other specialists

c. developing nationally-standardised maternity clinical information that can be electronically shared between health professionals

d. improving the collection of maternal and newborn information.

8. While the Maternity Action Plan did not proceed, the Ministry of Health prioritised

implementation of these four actions (now known as the Maternity Quality Initiative). The Maternity Quality Initiative is being implemented with close input from clinical experts, professional bodies and maternity consumers across the sector. Timeframes and detail about the four actions are outlined:

Maternity Quality Initiative: Further detail and timeframes

I Development of a national quality and safety programme

This programme includes development of national standards, clinical indicators, revised

DHB service specifications, and regular clinical review of maternity services. The

standards, service specifications and clinical indicators will be finalised by the end of

2010/11.

II Updated guidelines for referrals between Lead Maternity Carers, obstetricians and other specialists.

The guidelines will help ensure mothers and babies are referred or transferred to the most appropriate clinician when required, including in an emergency. They will be finalised by the end of 2010/11.

III Development of nationally standardised maternity clinical information that can be electronically shared between health professionals.

Development of electronic sharing of information between professionals is being piloted in one DHB, and will be nationally implemented by 2014.

IV Improvement of maternal and newborn information collection.

The Ministry of Health is improving its maternity “data warehouse” so the quality and

safety of maternity services can be better monitored. The improved warehouse will be

functional from 1 July 2011.

9. The Maternity Quality Initiative is designed to complement, rather than duplicate, existing health sector legal and policy requirements that are already in place. These include:

a. protection of consumers’ rights under the Health and Disability Commissioner’s Code of Consumer Rights

b. regulation of health practitioners under the Health Practitioners Competence Assurance Act 2003

c. regulation of maternity services provided in hospitals under the Health and Disability

Services (Safety) Act 2001

d. nationwide service specifications for primary, secondary and tertiary maternity services and facilities, such as the Primary Maternity Services Notice 2007 and service specifications for DHB-provided maternity facilities and services

e. reviews of perinatal and maternal mortality and morbidity through local mortality reviews and the Perinatal and Maternal Mortality Review Committee in accordance with the New Zealand Public Health and Disability Act 2000.

10. The Government’s response is presented for each of the Health Committee’s

recommendations.

Recommendations and Government response

Recommendation 1

The Health Committee recommends to the Government that it urge the key providers (midwives, obstetricians, paediatricians, GPs, and anaesthetists) and consumers to continue to develop a collaborative non-fragmented model of maternity care in New Zealand. The guidelines used to improve the system should be based on research, evidence, and best practice. We believe it would be helpful for the leaders of the relevant professions and consumers to meet formally on a regular basis to keep best-practice guidelines up to date. Every effort should be made to ensure a smooth

continuum of care from early pregnancy to the post-natal period. To avoid fragmentation, all parties should collaborate and share information.

Response

11. The Government is committed to a collaborative non-fragmented model of maternity care in New Zealand. One of the aims of the Maternity Quality Initiative (see paragraphs 7 and 8) is to improve collaboration and reduce fragmentation between hospital-based and community based maternity services. The Maternity Quality Initiative includes a national quality and safety programme, which has the intention of improving coordination across maternity services through multidisciplinary clinical quality improvement activities, a set of New Zealand Maternity Standards and New Zealand clinical indicators. In 2010/11, four DHBs will act as demonstration sites for clinical quality improvement activities. The sites will strengthen their clinical leadership in both hospital and community-based maternity services; develop local maternity networks that bring together practitioners from community and hospital settings; and develop mechanisms for effective consumer engagement. These networks will be used to strengthen clinical review and audit of local maternity issues. The DHB demonstration sites will inform national approaches and guidance for other DHBs.

12. The Government agrees that best practice guidelines should be used in New Zealand. In the Maternity Quality Initiative, the Ministry of Health is updating referral guidelines and developing processes for transfer of care, including in an emergency. These guidelines will improve collaboration and communication in the provision of maternity care, and identify where clinical responsibility lies. The Ministry of Health has also established a working group of clinical experts from the maternity sector that will develop a national set of evidence informed clinical guidelines. The national guidelines will improve quality and national consistency in clinical practice for a number of important maternity-related conditions.

Recommendation 2

The Health Committee recommends to the Government that it consider establishing an independent national perinatal epidemiology unit for collecting data on all births as part of its Maternity Quality Initiative. Part of its function would be to provide a feedback mechanism for communicating information and lessons learnt to midwives and clinicians. Subsequently the Government might consider a single data collection agency to avoid duplication.

Response

13. The Government agrees that improved monitoring and reporting of maternity events and outcomes for mothers and their babies will support quality improvement for health practitioners, services and DHBs. The PMMRC reviews and reports on perinatal and maternal mortality, with a view to reducing these deaths and to continuous quality improvement. The PMMRC has recently begun collecting data on major morbidities, and expanding its analysis of potentially avoidable factors.

14. The Ministry of Health has also prioritised improving its collection of maternal and newborn information by rebuilding the national maternity “datamart”. The Ministry of Health’s national maternity datamart is the only central repository with national coverage of maternity information. The Government’s Maternity Quality Initiative intends to improve mechanisms for using this data to guide policy and clinical practice by creating Maternity Clinical Indicators that are used to benchmark DHB performance. Improved national maternity data will also support the PMMRC’s work and other quality improvement activities.

15. The Government considers that the Health Quality and Safety Commission will provide the intended function of a national perinatal epidemiology unit. Some of the proposed functions of the Health Quality and Safety Commission are to advise the Minister of Health on any matter relating to health epidemiology and quality assurance, to determine quality and safety indicators for use in measuring the quality and safety of health services, to provide public reports on the quality and safety of health services, and promote and support quality improvement within the health sector. The Perinatal and Maternal Mortality Review function is to be part of the Commission’s responsibility.

16. The Health Quality and Safety Commission’s capability in epidemiological analysis and mortality review, combined with the Ministry of Health’s improved national maternity data and feedback mechanisms, are likely to provide the necessary elements for effective maternity monitoring, reporting and quality improvement.

Recommendation 3

The Health Committee recommends to the Government that it develop guidelines for all providers, including the coroner, for the process of investigation and for communication with the bereaved family, following the referral of a perinatal death to the coroner.

Response

17. The Government supports the need for all providers to deliver appropriate support to families affected by adverse birth events (see response to recommendation 10).

18. The Government notes that the Coroner has judicial independence. The Government cannot develop guidelines for the Coroner, as this will limit his judicial independence. In addition, New Zealand Police already have guidelines for the referral and investigation of cases reported to the Coroner. The Government has referred this recommendation to the Chief Coroner for his consideration.

Recommendation 4

The Health Committee recommends to the Government that it require GPs to formally refer pregnant women to lead maternity carers before the tenth week of pregnancy. This would ensure that the appropriate screening tests could be carried out in a timely way.

Response

19. In presenting this recommendation in its report, the Health Committee emphasised the importance of information sharing between practitioners. The Government agrees with the Health Committee’s view that it is important for women to be able to access maternity services and for information to be shared between practitioners. Further work would need to be done with the Royal New Zealand College of General Practitioners, New Zealand College of Midwives, and Royal Australia and New Zealand College of Obstetricians and Gynaecologists to determine whether a formal referral process is the most effective way of sharing information between practitioners and ensuring early access to maternity services.

20. The Government considers that a higher priority than a formal referral is information provision to women and information sharing with LMCs. The majority of women see their General Practitioner (GP) to confirm pregnancy and receive first trimester care. It is important that GPs provide information to women about screening tests that they may choose to have, and share information with LMCs about the woman’s health background. The Government notes that under the Primary Maternity Services Notice 2007 pursuant to section 88 of the New Zealand Public Health and Disability Act 2000 (the Notice), GPs providing first trimester services must inform women about options for choosing an LMC, provide information to women about screening, and offer a referral for a screening test. They must also provide screening test results and relevant health information to the woman and her LMC on care provided. In addition, GPs’ professional responsibilities require them to provide appropriate health information to consumers and other health providers.

21. The development of nationally-standardised maternity clinical information that can be electronically shared between health professionals (part of the Government’s Maternity Quality Initiative described under paragraphs 7 and 8) will be a useful tool to support sharing important health information between GPs, LMCs, obstetricians and other maternity providers.

Recommendation 5

The Health Committee recommends to the Government that there be formal referrals back to the GP by six weeks post-partum, containing a summary of pertinent facts.

Response

22. The Government agrees with this recommendation. The Government notes that this

recommendation is already a requirement under the Primary Maternity Services Notice 2007 pursuant to section 88 of the New Zealand Public Health and Disability Act 2000. Section DA10 of the Notice requires that:

a  “a transfer of the care of the woman and the baby from the LMC to the woman’s primary health services provider must take place before 6 weeks from birth.

b  The LMC must give a written referral to the woman’s general practitioner that meets the guidelines agreed by the New Zealand College of Midwives and the Royal New Zealand College of General Practitioners, before discharge from lead maternity care.

c  If a woman does not have a regular general practitioner, the maternity provider must

inform the woman about the primary health services available in the local area”.

23. In responding to this requirement, the New Zealand College of Midwives and the Royal New Zealand College of General Practitioners have agreed on the information that needs to be shared when a woman and baby are referred. They have developed a template to be completed by the LMC and forwarded to the woman’s GP.

Recommendation 6

The Health Committee recommends to the Government that information relating to ongoing wellchild care be relayed to parents according to best practice guidelines.

Response

24. The Government agrees that information be given to parents about access to Well Child services and transfer of care. The Government notes that provision of this information is a requirement under the Primary Maternity Services Notice 2007. Section DA29 of the Notice outlines that as part of postnatal visits, an LMC must provide care and advice to the woman about the care of her baby and access to services, outlined in the Well Child Tamariki Ora National schedule. Section DA9 of the Notice also provides specifications for transfer of care of the baby from the LMC to Well Child services. Under DHB service specifications for maternity services, providers of pregnancy and parenting education (antenatal classes) are also required to provide information about Well Child services and how parents access them.

Recommendation 7

The Health Committee recommends to the Government that the Ministry of Health continue to commission consumer satisfaction surveys at appropriate intervals. These surveys should be independently provided and of the highest possible quality to secure robust information.

Response

25. The Ministry of Health has commissioned consumer satisfaction surveys in 1999, 2002 and 2007, and is currently commissioning another survey to be implemented by an external agency in early 2011. Consumer feedback is important to the quality of maternity services. The surveys provide the Ministry of Health with a regular and comprehensive analysis of women’s perceptions of maternity services, enable the Ministry of Health to assess the current framework for primary maternity services, and provide information to inform future planning.

26. In the 2007 survey, consumers were generally satisfied with maternity services. Compared to the 2002 survey, there was an increase in the percentage of women who knew that they had to register with an LMC, who were given a copy of the care plan to keep, were told about the back-up care if their LMC couldn’t make herself available and those who were able to meet this back-up LMC during their pregnancy. There was also an increase in the number of postnatal home visits made by the LMCs and the percentage of women who knew which Well Child Providers were going to provide the Well Child visits.

Recommendation 8

The Health Committee recommends to the Government that it develop a suitable mechanism to assess the views of parents whose babies suffered serious adverse events or died before or during birth.

Response

27. Previous Ministry of Health-funded consumer satisfaction surveys have not included women who have had a perinatal death, because the survey methodology (postal) and type of questions were not considered appropriate for this cohort. The Ministry of Health recognises the importance of receiving feedback from this group about their views on the maternity services and bereavement support that they received.

28. In the 2011 consumer satisfaction survey, the Ministry of Health is commissioning a separate survey for bereaved women who have had a perinatal death. This includes women who have had a termination for fetal abnormality after 20 weeks of pregnancy, had a stillbirth after 20 weeks of pregnancy, or lost their baby up to 28 days following birth. The survey design will be tailored to this group, using the guidance of organisations such as Stillbirth and Neonatal Death Support (SANDS). Results of the survey will be used to inform future planning and will be communicated to DHBs, which provide support to parents whose babies have suffered adverse events.

Recommendation 9

The Health Committee recommends to the Government that it require both the Medical Council of New Zealand and the Midwifery Council of New Zealand to ensure that new graduates have significant post-graduate monitoring, supervision, and education updates, before going into independent practice. In our view, with regard to midwives, this should be for at least a year after graduation. All graduates should be subject to the requirements of continuous peer review, audit, and educational updates for as long as they are in practice. This is currently the expectation, but it is our view that it should be a requirement.

Response

29. The Government supports the intention that all new graduates have appropriate postgraduate monitoring, supervision, and education updates. Under the Health Practitioners Competence Assurance Act 2003, regulatory authorities such as the Medical Council of New Zealand and the Midwifery Council of New Zealand are independent statutory bodies. The Minister of Health cannot require them to make professional requirements compulsory.

30. There is no supervision programme in place for new medical graduates providing maternity care. There is a voluntary Midwifery First Year of Practice mentoring and supervision programme for graduating midwives, which is currently funded by the Ministry of Health. The programme has a high uptake of around 98 percent of graduating midwives. (The only new graduates not enrolled in it are not currently working as midwives or have left the country.)

31. The Minister of Health has formally communicated to both regulatory authorities the Government’s support for appropriate post-graduate monitoring, supervision and education updates. The Ministry of Health will work with the Medical Council of New Zealand and the Midwifery Council of New Zealand to determine what mechanisms could be used to implement, and the associated costs of, compulsory supervision programmes.

Recommendation 10

The Health Committee recommends to the Government that the Ministry of Health provide better coordinated support through DHBs and community groups for families affected by adverse birth events.

Response

32. The Government supports the need for coordinated support for families affected by adverse birth events, and acknowledges that this support is variable across all DHBs. There is currently a lack of clarity regarding requirements on DHBs to plan and fund these support services for their populations. As part of the Maternity Quality Initiative, the Ministry of Health is currently reviewing and updating service specifications for DHB-funded maternity services. The Ministry of Health is also reviewing the DHB Service Coverage Schedule. During these reviews, the Ministry will consider how existing requirements for DHBs to provide support services, including bereavement services and support for grief and loss, can be strengthened and clarified.

33. The Ministry of Health will also communicate with DHBs about the findings of the consumer satisfaction survey of bereaved women, and emphasise that DHBs use these findings to strengthen their planning of coordinated support for bereaved families (see response to recommendation 8).

Recommendation 11

The Health Committee recommends to the Government that it vigorously implement its Maternity Quality Initiative, which involves the development of a national quality and safety programme to help ensure delivery of the best possible maternity services, and to ensure New Zealand maternity services continue to be of high quality updating the guidelines for referrals between lead maternity carers and obstetricians and other specialists. These guidelines help ensure mothers and babies are referred or transferred to the most appropriate clinician when required the development of nationally-standardised maternity clinical records to support the electronic transfer of information between health professionals the improvement of the collection of maternal and newborn information so the quality and safety of maternity services can be monitored better.

Response

34. The Government continues to support the implementation of the Maternity Quality Initiative (see paragraphs 7 and 8). The Ministry of Health is actively working with the maternity sector in developing the initiative. There continues to be strong sector support for the initiative, with a high degree of consensus among clinical and sector stakeholders involved in the working groups. National implementation of the initiative will commence from 1 July 2011.

Recommendations 12, 13 & 14

The Health Committee recommends to the Government that it note the key points of the Perinatal and Maternal Mortality Review Committee’s report to the Minister of Health, Perinatal and Maternal Mortality in New Zealand 2007.

The Health Committee recommends to the Government that it review and note the relevant recommendations of the 1999 maternity review. (Some of us consider that the remaining points of the Draft Maternity Action Plan should be given further consideration.)

The Health Committee recommends to the Government that it take serious note of the petition of Jennifer Maree Hooper.

Response

35. The current Maternity Quality Initiative and other national initiatives will address some of the recommendations made in these documents. The documents continue to inform maternity policy. The Government notes that these documents may also inform future actions, once the Maternity Quality Initiative is implemented.

Conclusion

36. The Government supports the Health Committee’s report, and emphasises that it reflects current priorities within the maternity sector, particularly with the Maternity Quality Initiative.

The Government will conduct further work on recommendations not yet being implemented.