DHSC - Safe Staffing in Maternity Project

Purpose and Background of the Project

Several high-profile enquiries, most recently the Ockenden Report, have highlighted the need to gain a deeper understanding of what constitutes safe staffing in maternity care. 90% of obstetrics and gynaecology (O&G) junior doctors report rota gaps in their units and attrition and burnout rates are high at all career stages. Obstetric incidents can be catastrophic and life-changing for women and their families. In 2019/20 maternity litigation claims accounted for 50% of the value of new negligence claims against the National Health Service (NHS), almost £2.4 billion. By comparison, Health Education England’s (HEE) entire postgraduate medical training budget for all specialties is approximately £2 billion. In light of the above the Department Health Social Care (DHSE) commissioned the Royal College of Obstetricians and Gynaecologists (RCOG)– with its unique position as the professional body for the maternity (obstetric) workforce to undertake the development of a tool that would capture the state of staffing and explore links to quality outcomes.

Birthrate Plus exists as a framework to calculate safe midwifery staffing levels (https://birthrateplus.co.uk/). However, no such tool exists for medical staffing. Medical staffing is complex due to a multitude of factors at the unit, regional and national levels:

- Internal factors (i.e. medical staffing, national service configuration factors, local service delivery factors);

- External factors (i.e. local population factors and patient factors);

- Safety and Quality outcome measures (i.e. hospital reporting systems, external data and patient experience data).

The purpose of this project is to undertake a rapid research and workforce planning exercise to determine the number of obstetricians and anaesthetists required in maternity units across England. This will produce estimates of the number of staff required which can be used for local and national planning. A key aspect of this is the calculation of ‘complexity adjusted births’, a birth rate for each maternity unit that reflects the case-mix used by that hospital.

The study team are aware of the sensitivity of investigating maternity care. The study team do not intend to negatively identify maternity units or Trusts, data will be used to quantify the ‘value’ of births in each area based on demographics. This will be done by using HES data to develop a unit / trust profile for each unit / trust including descriptive statistics regarding maternal age, maternal comorbidities (as defined by National Institute for Health and Care Excellence (NICE)), maternal parity and previous obstetric history, ethnicity and socioeconomic deprivation. The study team have been selected to include a wide range of stakeholders and experts in the Steering Group (a panel of clinical and academic experts, including obstetricians, anaesthetists, midwives, statisticians and health service researchers). The role of this group is to provide broader multidisciplinary workforce issues and advise as to engagement with the wider Obstetric and Gynaecology community. Outputs, using aggregated data with small numbers suppressed in line with the HES analysis guide, will be used to co-produce any publications as a team in order to respect the sensitivity of this topic.

For further details, please see the DHSC Tool: Project Plan.

Project plan

This project aims to answer three questions using routinely collected maternity data:

(1) What is the current need for obstetricians and anaesthetists in England, at all levels, both at unit level and nationally, on an annual basis?

(2) How does this relate to the number and complexity of births in each maternity unit?

(3) How does staffing relate to maternity safety outcomes?

How data provided by NHS Digital will be used in the study

This study will use Hospital Episode Statistics (HES) Admitted Patient Care (APC) data on mother and child provided by NHS Digital (NHSD).

Patient-level data will allow the formulation of complexity-adjusted births. The addition of the formulation of complexity-adjusted births to the tool will give a national standard for quantifying the characteristics of births in each area based on demographics (parity, the number of times a woman has given birth to a fetus (after 24 weeks of pregnancy or more) regardless of whether the child was born alive or was stillborn, previous mode of delivery, social deprivation, ethnicity, co-morbidities). This formula will strengthen the calculation of the number of obstetricians required as it will be tailored to the needs of the location population as opposed to using generic indicators of unit size. As the complexity of births will reflect a national standard for quantifying the ‘value’ of births in each area based on demographics, there are no straightforward negative nor positive results for it. Data from NHS Digital on maternity demographics, medical history and outcomes is not currently published by Trust and thus pseudonymised data is required in order to generate these totals and enable further investigation. Requesting HES data minimises the data burden on NHS staff by ensuring the project uses routinely collected data.

Data will be restricted to a cohort for births from 1st January 2018 to 31st December 2021 that is derived from hospital admissions records that contain valid information about either mode of delivery or outcome of delivery. The study team estimate that this will be approximately 3 million women and their babies. All historic admissions episodes from 2000-2017 should be provided for all individuals with a record in this cohort. By looking at women’s previous admissions in HES, it is possible to derive their previous medical and maternity history. The level of data completeness in HES has improved over time but varies across NHS hospitals. Information not contained in the maternal record, like co-morbidity, could be sought from diagnosis codes in the records of previous admissions (J N Armitage, J H van der Meulen, on behalf of the Royal College of Surgeons Co-morbidity Consensus Group, Identifying co-morbidity in surgical patients using administrative data with the Royal College of Surgeons Charlson Score, British Journal of Surgery, Volume 97, Issue 5, May 2010, Pages 772–781, https://doi.org/10.1002/bjs.6930). Furthermore, the study team propose to augment information related to parity and previous caesarean birth using an established look-back method, which uses previous birth records in HES (Cromwell DavidA, Knight HannahE, Gurol-Urganci Ipek. Parity derived for pregnant women using historical administrative hospital data: Accuracy varied among patient groups. Journal of Clinical Epidemiology 2014;67:578–85. doi:10.1016/j.jclinepi.2013.10.011). That information will be part of the complexity of births needed to be able to compare Trusts providing maternity care. Since this is a national project, data from all English NHS trusts is required.

Patient level data will be analysed with the aim of exploring factors that may be associated with the required size of the obstetric workforce and to inform benchmark comparisons available in a final online tool. Data provided by NHS Digital will be used to provide a more detailed evaluation of the complexity of births handled in each individual hospital Trust and to identify possible outcome indicators that may be sensitive to variation in staff workload. (There will also be a flow of data from the devolved nations). Data on the number of available obstetricians and anaesthetists will be obtained from a census survey of the obstetric and anaesthetic workforce in England on a Trust/unit level, conducted by the RCOG via email correspondence using an online marketing platform known as “Dot Digital" with Clinical Directors. The aim of the census is to collect specific information on the number of available obstetricians and anaesthetists, including

• The number of consultants in each speciality

• The number of registrars (NTN, MTI, and SAS) in each speciality

• The number of PAs available at consultant level, including PAs dedicated to specific clinical activities

• Staffing ideals concerning the number of consultants, registrars and Pas required to ensure safe obstetric

It is anticipated that this will be an annual or biannual exercise to determine staffing requirement and availability for medical staff within maternity services in England, Wales, Scotland and Northern Ireland. Results from the census data will be aggregated and anonymised with small numbers suppressed to avoid accidental identification of the staff. The descriptive statistics may be plotted against measures of maternity outcomes in order to make conclusions about correlations between staffing and safety. This will be done by linking aggregated data from the census to the aggregated data from NHS Digital, and equivalent providers from the devolved nations, at a Trust/Board level. In publications with these descriptive statistics plotted in this way, Trusts/Boards will not be directly identified. All data collected will be handled in accordance with current data protection legislation. The aim of this data collection is to minimise the burden on Trusts to provide data, and to ensure consistency with other national projects (such as the Maternity Dashboard in England). It is recognised that due to heterogeneity in national data collection between England, Wales, Scotland and Northern Ireland, the set of metrics used in each country may not be precisely comparable.

The project anticipate answering two questions:

1. The project will assess associations between case mix and staffing (unit / trust level) in order to estimate how case mix may influence staffing requirements

2. The project will use individual patient data to estimate associations between case mix and selected outcomes. The results of these models will be used to identify expected outcomes for each unit / trust (given the case mix).

It is anticipated that Trust specific results will be displayed directly in the online tool that will be produced by the RCOG in collaboration with HEE who will provide the technical support required to create the tool in Tableau. Intellectual leadership and design, and direction of the tool content, will be provided by the RCOG.

The initial intended structure of this workforce tool is:

• To display the number of obstetric staff (Consultants, SAS (Specialty Doctors and Associate Specialists), LED (Locally Employed Doctors), Anaesthetists in each unit and how this compares to units of a similar size/patient demographics.

• To show the factors impacting on obstetric staffing and quantify these in each unit.

• To display outcomes and safety metrics which are felt to be contributed to by obstetric staffing levels.

The tool will show each individual unit on a separate page with their own statistics. It will also show where they lie nationally by using combined data from all units to produce median values and other summary statistics.

The principal aims of this tool are:

• To allow calculation of the number of obstetricians and obstetric anaesthetists required at unit level and nationally based on the median values from our existing staffing. This will give an initial answer of how many obstetricians are required, however accuracy relies on current median staffing levels to be appropriate.

• To allow the data to be displayed in an accessible format to allow units visualisation of where they sit in contrast to other obstetric units. This will aid in units’ ability to develop and assess their staffing.

• All the outputs from the analysis of the data in the tool will be aggregated and anonymised with small numbers suppressed to avoid accidental identification of the staff and woman involved.

In the first instance the tool will be hosted by HEE, until February/March 2023. The project will determine how the tool will be hosted and shared going forward.

Organisation involved:

The organisation involved in data processing for the study is the Royal College of Obstetricians and Gynaecologists (RCOG), supported by researchers from the University of Southampton and from Health Education England (HEE). The university of Southampton will provide methodological support in developing the statistical analysis of the data. The statistical analysis will be carried out by the RCOG statistician under supervision of University of Southampton. The University of Southampton will not determine the means and the purpose of the processing. HEE will be providing analytical input and processing the data but will not determine the means and purpose of the processing. The project was commissioned by the Department of Health and Social Care to understand the requirements for maternity staffing. The RCOG is leading and hosting the project and is the sole data controller and determining the purpose and means of the processing of the data. DHSC is the project sponsor and do not have the ability to exercise control over the processing of the personal data. DHSC have agreed with this through a UK GDPR compliant contract and confirmed that RCOG are the sole data controller. RCOG is the sole data controller and such as, its employees will process the data. According to the guidelines by the Information Commissioner’s Office (ICO)( https://ico.org.uk/media/for-organisations/documents/1546/data-controllers-and-data-processors-dp-guidance.pdf) a data processor is anyone who processes personal data on behalf of the data controller (excluding the data controller's own employees). Under these circumstances, RCOG is not required to be identified as a data processor.

The RCOG safe staffing team has determined means and purposes of the processing, which information from the census, publicly available data and HES will inform the workforce-staffing tool, and which items from HES will be used to derive the ‘complexity adjusted birth’. HEE and University of Southampton are both data processors. HEE will apply and analyse publicly available datasets (i.e. Maternity Dashboard), results from the workforce census survey and HES to create the workforce-staffing tool on Tableau. Statisticians from the University of Southampton are advisory to the data processing methodology. Individuals from the University of Southampton will not be determining the purposes or the means of data processing. University of Southampton will supervise the statistical analysis carried out by the RCOG using aggregated census data, the publicly available data and the pseudonymised data from HES. Data from HES will help to derive the 'complexity adjusted birth' value. Which will be incorporated into the workforce-staffing tool. All contracts with named data processors will be UK GDPR compliant using a standard RCOG UK GDPR contract with data protection schedule. All processing activities will be specified in the UK GDPR compliant contracts with both organisations using a standard RCOG UK GDPR contract with data protection schedule.

All of the people processing the data are substantive employees of the data controller and/or data processors. The processing activities are covered in UK GDPR compliant contracts as well as the project plan.

Data security and legal basis

The RCOG has a secure data access environment (hosted by RedCentric PLC) which is where the data will be kept and used by employees of the RCOG (all individuals involved in the data processing who are not substantively employed by the RCOG will have their involvement covered by a UK GDPR compliant contract with their substantive employer).

Only individuals primarily employed by HEE, the University of Southampton or the RCOG will have access to the data on RCOG systems.

No copies of the NHS Digital data will be held at the University of Southampton or at HEE. Both institutions will be processing the data via the RCOG’s secure server hosted by RedCentric PLC. Redcentric PLC supply IT infrastructure and Cloud Services for the RCOG and are therefore listed as a data processor. They supply support to the system, but do not access data. Therefore, any access to the data held under this agreement would be considered a breach of the agreement. This includes granting of access to the database[s] containing the data.

RCOG’s legal bases for processing the requested pseudonymised patient level data:

The RCOG has reviewed the purposes of our processing activities, and selected the most appropriate lawful basis: Article 6 (1) (f). The project will be processing data to:

• Improve the future workforce pipeline for obstetric staffing

• Support the delivery of safe obstetric care in maternity units across England

• Minimise litigation burden on the NHS.

Processing the data will also enable an in-depth analysis, including exploration of factors that may be associated with the required size of the obstetric workforce, and to inform benchmark comparisons between units by comparing unit case mix.

Where the project process special category data, the project have also identified a condition for processing special category data, and have documented this (art. 9(2)(i)). Article 9(2)(i): "Processing is necessary for reasons of public interest in the area of public health, such as protecting against serious cross-border threats to health or ensuring high standards of quality and safety of health care and of medicinal products or medical devices, on the basis of Union or Member State law which provides for suitable and specific measures to safeguard the rights and freedoms of the data subject, in particular professional secrecy";

Recital 54 of GDPR explains that:

“The processing of special categories of personal data may be necessary for reasons of public interest in the areas of public health without consent of the data subject. Such processing should be subject to suitable and specific measures so as to protect the rights and freedoms of natural persons. In that context, ‘public health’ should be interpreted as defined in Regulation (EC) No 1338/2008 of the European Parliament and of the Council¹, namely all elements related to health, namely health status, including morbidity and disability, the determinants having an effect on that health status, health care needs, resources allocated to health care, the provision of, and universal access to, health care as well as health care expenditure and financing, and the causes of mortality. Such processing of data concerning health for reasons of public interest should not result in personal data being processed for other purposes by third parties such as employers or insurance and banking companies”

Furthermore, as per the ICO guidance; if you are relying on conditions (b), (h), (i) or (j), you also need to meet the associated condition in UK law, set out in Part 1 of Schedule 1 of the DPA 2018.

For Public health

3: This condition is met if the processing—

(a) is necessary for reasons of public interest in the area of public health, and

(b) is carried out—

(i) by or under the responsibility of a health professional, or

(ii) by another person who in the circumstances owes a duty of confidentiality under an enactment or rule of law.

In this instance, the project is the responsibility of the Director for Clinical Quality who as a qualified nurse is also the College’s Caldicott Guardian. Additionally the project sponsor is the Vice President for membership and the project reports through the RCOG governance structure to the RCOG Council.

This project supports the need for the healthcare system to be adequately staffed by providing a tool that will guide maternity care units in planning for an appropriate number of obstetricians and obstetric anaesthetists based on their own complexity of births.

Reference

Ockenden Report

https://www.gov.uk/government/publications/ockenden-review-of-maternity-services-at-shrewsbury-and-telford-hospital-nhs-trust

Ockenden Report Final Report

https://www.gov.uk/government/publications/final-report-of-the-ockenden-review

NHS Digital will identify a cohort of approximately 3 million women and babies from birth and birth records between 1st January 2018 to 31st December 2021. Records of each episode of birth or birth happened in the mentioned period, will be defined as index admission. For all the individuals with a record in this cohort, the RCOG are also requesting the same data from all historic admission episodes back to 2000, to derive historical information.

NHS Digital will return pseudonymised record level data to the Royal College of Obstetricians and Gynaecologists (RCOG) via secure file transfer. The Hospital Episode Statistics (HES) Admitted Patient Care (APC) extract will contain birth episodes for the identified cohort, containing valid information about either mode of birth or outcome of delivery. RCOG will provide the data specification in terms of appropriate episode type, OPCS-4 procedure and ICD10 diagnosis codes to identify delivery and birth episodes for data extraction. All historical and future (i.e. following birth) HES APC records for mothers and babies identified in the previous step will also be included within the files.

The historic admission episodes for the cohort of births from 1st January 2018 to 31st December 2021 (records for both women and babies) back to 2000 are fundamental for the project i.e. all the maternity variables together with diagnostic and procedure codes. This will enable the derivation of previous birth history and previous significant medical history relating to the hospital admission episode, and allow RCOG to augment ethnic coding using historical codes. That will be done through processes explained in the literature (e.g. DOIs: 10.1016/j.jclinepi.2013.10.011; doi.org/10.1136/bmj.m3377; 10.1111/1471-0528.12508). This information will be part of the complexity of births needed to be able to compare Trusts providing maternity care. Once the variables required (parity, previous caesarean, previous preterm birth, previous stillbirth, previous ethnicity, previous diagnoses, previous procedures) have been derived, these historical records will be destroyed and only the cohort with the index admission records will be kept: i.e. all admissions which are not the index admission will be deleted. A data destruction certificate will be made available to NHS Digital on request. Episodes of care after the index admission episode will allow the identification of re-admissions mothers and babies after birth in terms of number and causes but not the individual patient.

Only data items which are necessary for the project are requested, with one or more of the following purposes:

- to determine which provider or maternity unit administered the care;

- to determine the quality of care for the service user;

- to determine the nature of the episode and diagnosis;

- to determine the case-mix of service users with a particular provider or maternity unit ;

- to determine the health outcomes for the service user.

Pseudonymised patient level data from NHS Digital will be held within RCOG's secure data environment. This pseudonymised data will be processed within RCOG's secure data environment by both substantive employees of and employees of the contracted data processors (HEE and University of Southampton). All substantive employees of the data processors have a primary employment contract at either a University or with the NHS which also holds them to account regarding data processing. The secure research environment is accessed by two factor authentication.

The data will only be used to calculate and evaluate the complexity of births at each maternity unit. This will involve the calculation of rates and trends of key maternity safety and quality measures for each maternity unit.

The selection of characteristics used to evaluate complexity and measures used to evaluate the quality of maternity care in this project will be guided by a Steering Group (a panel of clinical and academic experts, including obstetricians, anaesthetists, midwives, statisticians and health service researchers). The Steering Group will only provide guidance but ultimately the decision will fall to the Study Team. The measures will be based upon information available from existing published research in this area using HES.

Characteristics used to evaluate complexity are anticipated to include:

- Maternal age

- Maternal comorbidities (as defined by NICE)

- Maternal parity and previous obstetric history

- Ethnicity and socioeconomic deprivation

- Other factors available in data judged to be likely contributors to complexity / workload

Measures used to evaluate the safety and quality of care are anticipated to include:

- Induction of labour

- Mode of birth

- Severe Maternal morbidity

- Obstetric anal sphincter injury

- Preterm birth

- Stillbirth

- Babies born small for gestational age (SGA <10th centile of birthweight; fetal growth restriction <3rd centile of birthweight)

- Maternal readmission following birth

There will be no requirement or attempt to re-identify the individuals involved in the data collection.

The project will use the requested data to produce three outputs:

• An online tool describing the summary characteristics, demand, and obstetric and anaesthetic staffing on an annual basis in NHS Trusts or Boards providing maternity services in England – target date ongoing

• A short report describing the numbers of obstetric and anaesthetic doctors required in England, and the methodology behind these calculations. The project will use analysed externally-produced metrics and aggregate patient data to produce the results for the short report. – February/March 2023

• Peer-reviewed publications describing the methodology behind the tool, and associations between maternity staffing and safety outcomes. The project will use analysed externally-produced metrics and aggregate patient data to produce the results for the peer-reviewed publications. – February/March 2023

The principal audience for the project’s outputs are the DHSC which has commissioned this analysis. Secondary audiences are clinical leaders, trust managers, and national policy leaders. The initial intended structure of this workforce tool is: to display the number of obstetric staff in each unit and how this compares to units of a similar size/patient demographics; to show the factors impacting on obstetric staffing and quantify these in each unit; to display outcomes and safety metrics which are felt to be contributed to by obstetric staffing levels. The tool will show each individual unit on a separate page with their own statistics. We envisage that each unit will be able to see only their data. The tool will also show where they lie nationally by using combined data from the rest of the units statistics to produce median values. . The final implementation of the tool will be determined by RCOG in partnership with key partners from the maternity system.

The aims of this tool are:

• To allow calculation of the number of obstetricians and obstetric anaesthetists required nationally based on the median values from our existing staffing. This will provide an initial answer of how many obstetricians are required, however accuracy relies on current median staffing levels to be appropriate. The use of HES data will allow a second calculation to be undertaken , specifically to create a complexity adjusted measure that will allow comparisons against not only numbers of birth, but the complexity of each birth,

• The development of this tool will allow the data to be displayed in an accessible format to allow units visualisation of where they sit in contrast to other obstetric units. This will aid in their ability to develop and assess their staffing.

In the first instance the tool will be hosted by HEE, until February/March 2023. The project will determine how the tool will be hosted and shared going forward. For the avoidance of any doubt – no patient level data will be included in the tool. It is all aggregated with small numbers suppressed.

It is anticipated that the results of this project will be used to inform maternity workforce development, specifically

• Modifications of the numbers of obstetric and anaesthetic doctors required in each maternity unit in England to improve safe birth outcomes.

The expected measurable benefits are hoped to include:

- A summary of the characteristics, demand, and obstetric and anaesthetic staffing on an annual basis in NHS maternity units in England

- A Workforce tool accessible by each maternity unit.

Planning for the right number of obstetricians and anaesthesiologists is critical to maintaining and improving the safety and quality of maternity services.

Current demands on maternity services are mainly being driven by increases in the complexity and acuity of many pregnancies and births. The Workforce tool will inform DHSC, Health Education England, Clinical directors, and managers with a detailed and broad picture of the current workforce levels and allow the assessment of the relationship between these and other factors like the complexity of births.

Results from this project will be directly available on the Workforce tool, which will be accessible online to each maternity unit. That will enable them to visualise where they sit in comparison to other obstetric units with the same complexity of birth, and where they sit on a national level. This will aid in their ability to develop and assess their staffing and help them in planning their workforce.

Direct Benefits to the Public

The long-term benefit of the workforce tool is to ensure that there is an adequate number of obstetricians and anaesthesiologists (also taking into account midwifery staffing) in each maternity unit based on each unit case-mix. This is expected to contribute to a reduction in adverse outcomes like maternal mortality and morbidity, and stillbirth. Obviously this is dependent on funding from Government to address any deficits in staffing levels identified by the tool. The steering group recognise the potential of better staffed units having a benefit for woman.

At this stage the project does not envisage other immediate direct benefits to women and families of maternity services, however, the study team are keen to explore what a public interface to the data might look like in further iterations of the tool that might sit alongside existing high-quality women and family facing information, to enable informed consent for those using our services. At this stage we the study team will engage the RCOG’s Women’s Voices Involvement Panel (https://www.rcog.org.uk/for-the-public/rcog-engagement-listening-to-patients/womens-voices-involvement-panel/)_ to ensure women’s voices are at the heart of any further developments.

Yielded Benefits is not a requirement for new applications.