Maternity Matters Choice, Access and Continuity of Care in a Safe Service

1. Maternity MattersChoice, Access and Continuity of Care in a Safe Service Caroline Donovan Deputy�Head of Workforce Development West Midlands Workforce Deanery General welcome. Acknowledgement of a good range of stakeholders, geographically and profession Thanks for making the time to attend & participate. Intro will cover: Aims of day Format & housekeeping Support for the region in implementing Maternity Matters has taken place over two events. The initial stakeholder meeting with the policy launch and service implications was held in May which some of you I know attended. Today's event is the second event. The Department of Health has asked the National Workforce Projects and NHS West Midlands to support the workforce planning element with a series of workforce planning capability workshops to ensure that any development plans integrate service and workforce needs. The NSF for Children, Young People and Maternity Services, the White Paper Our Health, Our Care, Our Say and Maternity Matters have set out a new pattern for the delivery of maternity services with an increasing emphasis on choice, access and continuity of care. �� General welcome. Acknowledgement of a good range of stakeholders, geographically and profession Thanks for making the time to attend & participate. Intro will cover: Aims of day Format & housekeeping Support for the region in implementing Maternity Matters has taken place over two events. The initial stakeholder meeting with the policy launch and service implications was held in May which some of you I know attended. Today's event is the second event. The Department of Health has asked the National Workforce Projects and NHS West Midlands to support the workforce planning element with a series of workforce planning capability workshops to ensure that any development plans integrate service and workforce needs. The NSF for Children, Young People and Maternity Services, the White Paper Our Health, Our Care, Our Say and Maternity Matters have set out a new pattern for the delivery of maternity services with an increasing emphasis on choice, access and continuity of care. ��

2. Purpose and aims of today An opportunity to hear the key workforce challenges of Maternity Matters from a range of stakeholder perspectives Hear about the support, guidance and tools to help local workforce planners supporting delivery of Maternity MattersHear and share some local examples of good practice Through locality based discussions identify priorities, levers and challenges in implementation The workshop will support organisations in developing the integrated workforce plans that will be needed to deliver the new policy. Define regionally and locally our next steps Today�s event has been arranged in partnership with NWP, DH & SHA. We jointly recognise that effective delivery of Maternity Matters is a partnership agenda. Effective partnership at national, regional & local level will be key to delivery of Maternity Matters in the wider context of Every Child Matters and today's programme will help us think about how we produce good local workforce plans which link implementation of MM into wider strategic agendas like refreshing Children & Young Peoples plans, LDPs etc. Maternity services have a current priority and focus they have never previously enjoyed & it is our joint responsibility to ensure we make maximum use of this opportunity for sea change. Format and content: We have an excellent range of speakers from national and regional perspectives. We will hear about what Maternity Matters means for the workforce and we have built in time and opportunities for questions and reflections. Also over lunch we hope you find time to talk with colleagues, friends and speakers. It is widely recognised that having the right workforce in the right place with the right range of skills will be a major factor in the success of creating the kind of service, and service user experience we want to achieve. The NHS National Workforce Programme is working hard to support local workforce planning and workforce . Housekeeping: The programme is full and we want lots of opportunity for discussion so keeping to time will be a challenge. No fire alarms are planned. We will aim to finish by 2pm. Following on from the event in May, one of the biggest headaches of the group who organised today was to fit in all that it felt important to cover, without risking death by presentation/powerpoint, and ensuring you had a reasonable period of time with local colleagues to reflect, discuss and consider local priorities for action was vital. Peter Bythin will be joining us later. Today�s event has been arranged in partnership with NWP, DH & SHA. We jointly recognise that effective delivery of Maternity Matters is a partnership agenda. Effective partnership at national, regional & local level will be key to delivery of Maternity Matters in the wider context of Every Child Matters and today's programme will help us think about how we produce good local workforce plans which link implementation of MM into wider strategic agendas like refreshing Children & Young Peoples plans, LDPs etc. Maternity services have a current priority and focus they have never previously enjoyed & it is our joint responsibility to ensure we make maximum use of this opportunity for sea change. Format and content: We have an excellent range of speakers from national and regional perspectives. We will hear about what Maternity Matters means for the workforce and we have built in time and opportunities for questions and reflections. Also over lunch we hope you find time to talk with colleagues, friends and speakers. It is widely recognised that having the right workforce in the right place with the right range of skills will be a major factor in the success of creating the kind of service, and service user experience we want to achieve. The NHS National Workforce Programme is working hard to support local workforce planning and workforce . Housekeeping: The programme is full and we want lots of opportunity for discussion so keeping to time will be a challenge. No fire alarms are planned. We will aim to finish by 2pm. Following on from the event in May, one of the biggest headaches of the group who organised today was to fit in all that it felt important to cover, without risking death by presentation/powerpoint, and ensuring you had a reasonable period of time with local colleagues to reflect, discuss and consider local priorities for action was vital. Peter Bythin will be joining us later.

3. Welcome and enjoy the day! Summary We hope that the day is useful to you & you feel it was worthwhile of the cost of your valuable time. We welcome & need with your participation, it is certainly valuable to inform regional development priorities & action plans. Summary We hope that the day is useful to you & you feel it was worthwhile of the cost of your valuable time. We welcome & need with your participation, it is certainly valuable to inform regional development priorities & action plans.

4. Issues identified from the NHS WM/ DH/CSIP day � 15th May 2007 Sue Hatton Workforce Specialist West Midlands Workforce Deanery

5. Issues identified from the NHS WM/ DH/CSIP day � 15th May 2007 Wealth of expertise and good practice Useful to have an opportunity to air issues in safe environment To meet colleagues and find Commissioners (!) The need for local vision around maternity services. Areas are at different stages of development for implementation & there are specific local challenges. Self assessment benchmarking tool (SAM) useful Concerns about how to guarantee choice Importance of user involvement, clinical leadership and multidisciplinary working. Good networking event with lots of enthusiasm Good networking event with lots of enthusiasm

6. Cont�d Development of multi-agency care pathways with the right skills and competencies essential Maternal Mental Health pathway Workforce solutions/skill mix to increase workforce capacity e.g. MSW Need for more midwives, increase in training commissions and further development of the role of MSW (around home births) Community midwifery caseloads vary in between 90 to 180 per midwife. Return to Midwifery Practice How do we prepare clinicians/ have skills to offer choice Share good practice using CSIP Share & Spread site Care pathways are essential Maternal mental health featured strongly in the discussions and there is a network meeting on Wednesday 11th July In April 2005 the large-scale workforce change (LSWC) launched a programme to support the National Service Framework (NSF) for children, young people and maternity services. The programme ended in January 2006 with 57 trusts having been involved (10 from within the West Midlands) and the results of the programme shows demonstrable benefits across maternity services involved in the project. What influences a women�s� choice on a place of birth, pain relief etc� and to identify what new skills are needed around offering choice in maternity services in the future. The appropriate use of skill mix can target extra capacity to overcome workforce gaps and barriers Leadership and succession planning Progress the self assessment matrix (MM SAM) as a local and regional tool as a basis for the local action plans required by DH by autumn 2007. Care pathways are essential Maternal mental health featured strongly in the discussions and there is a network meeting on Wednesday 11th July In April 2005 the large-scale workforce change (LSWC) launched a programme to support the National Service Framework (NSF) for children, young people and maternity services. The programme ended in January 2006 with 57 trusts having been involved (10 from within the West Midlands) and the results of the programme shows demonstrable benefits across maternity services involved in the project. What influences a women�s� choice on a place of birth, pain relief etc� and to identify what new skills are needed around offering choice in maternity services in the future. The appropriate use of skill mix can target extra capacity to overcome workforce gaps and barriers Leadership and succession planning Progress the self assessment matrix (MM SAM) as a local and regional tool as a basis for the local action plans required by DH by autumn 2007.

8. Useful websites www.cypf.org.uk/maternity for resources relevant to Maternity Matters and sharing promising practice. www.cypf.org.uk/maternity/tools for links to the online maternity matters baseline self assessment Matrix to benchmark progress and support action planning and other key tools. http://kc.csip.org.uk/groups.php?grp=593 to join the discussion area.

9. New Challenges Commissioning Payment by results (PbR) Close (seamless) working with other organisations in new locations Closer working with women (choice) Development of current services within existing resources Variations across the region in trends in the birthrate Increasing complexity Deskilling of the primary care workforce is a major issue for obstetrics, as mothers opting for home births, delivery in remote midwife-led units or birthing centres or for very early discharge after delivery may need the services of a general practitioner perinatally. Today we will be looking at challenges around the workforce Deskilling of the primary care workforce is a major issue for obstetrics, as mothers opting for home births, delivery in remote midwife-led units or birthing centres or for very early discharge after delivery may need the services of a general practitioner perinatally. Today we will be looking at challenges around the workforce

12. SHA emerging priorities Secondary to Primary shift Long term conditions 18 weeks and diagnostics Women's and Children/young people Emergency care End of life care Mental Health Dentistry Public Health Empowered patients and self care

13. Future Workforce Direction Workforce which is designed around the needs of patients and can rapidly respond to expectations of public Workforce which matches demand and supply Workforce who is fit for purpose Flexible workforce who can work across teams and organisations Opportunities for continual increasing skills and career pathways that are flexible and respond to the service Leadership at all levels Widening participation A workforce which is representative of the community Safe and regulated workforce MHC careers Flexible workforce who can work across teams and organisations- multiple providersFlexible workforce who can work across teams and organisations- multiple providers

14. So what is the SHA role? Strategic overview of the workforce in line with SHA framework Commission for supply and quality assure provision Test and spread new ways of working and commission new roles Link with DH for Modernising Health Care Careers Recruit and train doctors Enable and support best HR practice Provide strategic leadership to assist PCTs in the development of the local vision for local maternity services, the development of networks and of user involvement Oversee and contribute to the development of the workforce strategy, workforce modernisation and workforce development � Ensure that opportunities exist for three year and 18 month pre-registration programmes and flexible return to practice midwifery programmes � Hold PCTs to account for commissioning comprehensive maternity services � Ensure that Local Supervisory Authority standards and activities promote safe, high quality care for women and their babies and monitor standards of midwifery practice � Ensure that the local community has representation on a local MLSC or equivalent and other user involvements groups e.g. LINKs Provide strategic leadership to assist PCTs in the development of the local vision for local maternity services, the development of networks and of user involvement Oversee and contribute to the development of the workforce strategy, workforce modernisation and workforce development � Ensure that opportunities exist for three year and 18 month pre-registration programmes and flexible return to practice midwifery programmes � Hold PCTs to account for commissioning comprehensive maternity services � Ensure that Local Supervisory Authority standards and activities promote safe, high quality care for women and their babies and monitor standards of midwifery practice � Ensure that the local community has representation on a local MLSC or equivalent and other user involvements groups e.g. LINKs

15. So what is the SHA role? Maternity Matters � workforce elements Lead the development of the NHS workforce strategy, workforce modernisation and workforce planning & development Ensure that opportunities exist for three year and 18 month pre-registration programmes, reduce attrition rates programmes and flexible return to practice midwifery programmes Hold PCTs to account for commissioning comprehensive maternity services Ensure that Local Supervisory Authority standards and activities promote safe,high quality care for women and their babies and monitor standards of midwifery practice Ensure that the local community has representation on a local MLSC orequivalent and other user involvements groups e.g. LINKs

18. How do we want to work? cost effective and efficient. demonstrate accountability for Multi Professional Education and Training (MPET) levy funds. being flexible in responding the workforce issues emerging from clinical and service priorities. working in partnership with key stakeholders egTrusts, FTs, PCTs, LSC, Skills for Health, NHS Institute, Social Care, Higher and Further Education and Voluntary and Independent Sector. demonstrating probity and sound corporate governance. ensuring that reducing inequalities and regenerating local communities is a core principle of operation.

19. Moving skills up/ down / across the career framework. Linked to KSFMoving skills up/ down / across the career framework. Linked to KSF

22. Main themes of maternity matters Choice of how to access maternity care Choice of type of antenatal care Choice of place of birth Home/Local facility/Hospital Choice of place of postnatal care Continuity of care In 2005, the Government underlined the importance of providing high quality, safe and accessible maternity care through its commitment to offer all women and their partners, a wider choice of type and place of maternity care and birth. Building on this commitment, four national choice guarantees will be available for all women by the end of 2009 and women and their partners will have opportunities to make well informed decisions about their care throughout pregnancy, birth and postnatally. By the end of 2009, four national choice guarantees will be available: Choice of how to access maternity care Choice of type of antenatal care Choice of place of birth. Depending on their circumstances, women and their partners will be able to choose between three different options. These are: � a home birth � birth in a local facility, including a hospital, under the care of a midwife � birth in a hospital supported by a local maternity care team including midwives,anaesthetists and consultant obstetricians. For some women this will be the safest option Choice of place of postnatal care This will be provided either at home or in a community setting, such as a Sure Start Children�s Centre As well as the choice of local options, a woman may choose to access maternity services outside her area with a provider that has available capacity. In addition, every woman will be supported by a midwife she knows and trusts throughout her pregnancy and after birth. by the end of 2009: � all women will have choice in where and how they have their baby and what pain relief to use, depending on their individual circumstances. This will be a national choice guarantee. In addition: � support will be linked closely to other services provided in the community, such as in Sure Start Children�s Centres, to improve accessibility and promote early integration with other services � every woman will be supported by a midwife she knows and trusts throughout her pregnancy and afterwards so as to provide continuity of care Transport arrangements should be in place to ensure that if something goes wrong any women giving birth at home can be transported to a consultant-lead unit as safely and quickly as possible. In 2005, the Government underlined the importance of providing high quality, safe and accessible maternity care through its commitment to offer all women and their partners, a wider choice of type and place of maternity care and birth. Building on this commitment, four national choice guarantees will be available for all women by the end of 2009 and women and their partners will have opportunities to make well informed decisions about their care throughout pregnancy, birth and postnatally. By the end of 2009, four national choice guarantees will be available: Choice of how to access maternity care Choice of type of antenatal care Choice of place of birth. Depending on their circumstances, women and their partners will be able to choose between three different options. These are: � a home birth � birth in a local facility, including a hospital, under the care of a midwife � birth in a hospital supported by a local maternity care team including midwives,anaesthetists and consultant obstetricians. For some women this will be the safest option Choice of place of postnatal care This will be provided either at home or in a community setting, such as a Sure Start Children�s Centre As well as the choice of local options, a woman may choose to access maternity services outside her area with a provider that has available capacity. In addition, every woman will be supported by a midwife she knows and trusts throughout her pregnancy and after birth. by the end of 2009: � all women will have choice in where and how they have their baby and what pain relief to use, depending on their individual circumstances. This will be a national choice guarantee. In addition: � support will be linked closely to other services provided in the community, such as in Sure Start Children�s Centres, to improve accessibility and promote early integration with other services � every woman will be supported by a midwife she knows and trusts throughout her pregnancy and afterwards so as to provide continuity of care Transport arrangements should be in place to ensure that if something goes wrong any women giving birth at home can be transported to a consultant-lead unit as safely and quickly as possible.

23. Where are we starting from? Excellent training Good reputation Lots of enthusiasm Wealth of expertise West Midlands traditionally have poor home birth rates High perinatal mortality rates Different models of practice around when women are booked, community midwifery caseloads etc..

24. Birth rate trend in England & Wales and the West Midlands. Mothers in WM are younger than the average for England Fewer home births (1.75%, England 2.5%)Mothers in WM are younger than the average for England Fewer home births (1.75%, England 2.5%)

25. But�. West Midlands Region has the highest perinatal mortality rate in England, and the gap is widening � 1.0% above the England rate in 1993, 1.9% above in 2005 Some areas have very high levels of deprivation As the maps show, perinatal mortality is closely related to deprivation. � Analysis by ward has identified several areas which have substantially higher mortality rates, e.g. in Stoke, Coventry and Worcester. At the event in May everyone heard about the specific project to reduce perinatal mortality underway in the former BBC area, based on: Continuity of care - 75% of visits to midwifery with named midwife Monitoring foetal growth restriction - 60% of growth restricted babies detected antenatally Early booking by 12 weeks - 80% in first trimester (12 weeks of pregnancy) As the maps show, perinatal mortality is closely related to deprivation. � Analysis by ward has identified several areas which have substantially higher mortality rates, e.g. in Stoke, Coventry and Worcester. At the event in May everyone heard about the specific project to reduce perinatal mortality underway in the former BBC area, based on: Continuity of care - 75% of visits to midwifery with named midwife Monitoring foetal growth restriction - 60% of growth restricted babies detected antenatally Early booking by 12 weeks - 80% in first trimester (12 weeks of pregnancy)

26. cont. Birth rates are much higher in some areas with younger populations � 50% of population in HOB is of childbearing age compared to 36% in Shropshire Increase in demand from migration from the accession countries to the WM (46,000), about one third of which are female and of childbearing age. (=1.6% of all women 15-44 in WM) This has a disproportionate impact in some areas There are variations across the region in trends in the birthrate. Areas with higher levels of BME population tend to have a higher proportion of people in younger age groups and therefore higher numbers of births In migrants from eastern Europe are a significant factor in some areas, but relatively small proportion of the population overall. May have a disproportionate impact on services in some rural areas. There are variations across the region in trends in the birthrate. Areas with higher levels of BME population tend to have a higher proportion of people in younger age groups and therefore higher numbers of births In migrants from eastern Europe are a significant factor in some areas, but relatively small proportion of the population overall. May have a disproportionate impact on services in some rural areas.

27. Current workforce There are 2,092 FTE midwives in the West Midlands (2,770 headcount) 5% increase in England but no increase in WM since 2001 - and 1.5% reduction 2005-2006 There has been very little change in the numbers of midwives and of support staff in the West Midlands. The reasons for the discrepancy between England and the W Mids are not clear. There has been very little change in the numbers of midwives and of support staff in the West Midlands. The reasons for the discrepancy between England and the W Mids are not clear.

28. Current workforce The non-registered maternity workforce in the WM has also changed little since 2001. Most midwives (80%) work part-time (>.9 FTE) Part time working has risen more in the West Midlands than England 3 month vacancy rates are low and have fallen from 0.9% in 2005 to 0.2% in 2006 Only 16 new graduates reported not to have found jobs in NHS in 2006/07 7 redundancies in 2006/07- all voluntary Although the numbers of support staff have changed little, this hides significant changes in their roles eg Maternity Support workers etc The increasing prevalence of part-time working means that more midwives are required overall to provide the same capacity (FTE). This may in part be a reaction to workload and stress. The low levels of 3 month vacancies suggests that recruitment problems are becoming less severe. Getting funding for new posts may be more of a problem than recruiting staff. Recruitment difficulties appear to vary between organisations, perhaps based on the perceived relative attractiveness of different areas and trusts Although the numbers of support staff have changed little, this hides significant changes in their roles eg Maternity Support workers etc The increasing prevalence of part-time working means that more midwives are required overall to provide the same capacity (FTE). This may in part be a reaction to workload and stress. The low levels of 3 month vacancies suggests that recruitment problems are becoming less severe. Getting funding for new posts may be more of a problem than recruiting staff. Recruitment difficulties appear to vary between organisations, perhaps based on the perceived relative attractiveness of different areas and trusts

29. Age profile of midwives in the WM Significant numbers of midwives are likely to retire over next 5 years 23% aged over 50, 10% over 55 There are likely to be larger numbers of midwives retiring in the longer term (5-10 years), as the current peak aged 45-49 moves towards retirement age . In comparison in London 35% are 50+ and 18% 55+. W Mids has similar age structure to England. There are likely to be larger numbers of midwives retiring in the longer term (5-10 years), as the current peak aged 45-49 moves towards retirement age . In comparison in London 35% are 50+ and 18% 55+. W Mids has similar age structure to England.

30. Future workforce The number of education commissions was increased by 10% in 2003/04 and 2004/05 � graduating in 2006 and 2007 This should lead to a slight overall increase in the numbers of midwives over the next 5 years There are 148 O&G consultants and 323 other medical staff. There are plans to increase the numbers of consultants in the medium term through changes to the training grades Nationally, there has been a much larger increase in the number of O&G consultants (+40%) than in midwives (+5%) since 1997 Past increases in education commissioning should start to feed through this year and next. Overall, there should be more midwives graduating than leaving/retiring over the next 4 years, enabling a growth in numbers. The larger increase in consultants is also reflected in other areas of the workforce, following government targets for increases in consultants in order to reduce waiting times We currently under produce our required number of O&G, not because there are too few posts but because we have tended to recruit doctors called fixed term training appointments (FTTAs), which are generally overseas drs who come to the UK to do a 1 or 2 year post at registrar level, but do not go on to achieve their CCT and become consultants. We plan to convert 40 FTTA posts into ST3+ posts over transition so that we increase our output of CCT holders in O&G.Past increases in education commissioning should start to feed through this year and next. Overall, there should be more midwives graduating than leaving/retiring over the next 4 years, enabling a growth in numbers. The larger increase in consultants is also reflected in other areas of the workforce, following government targets for increases in consultants in order to reduce waiting times We currently under produce our required number of O&G, not because there are too few posts but because we have tended to recruit doctors called fixed term training appointments (FTTAs), which are generally overseas drs who come to the UK to do a 1 or 2 year post at registrar level, but do not go on to achieve their CCT and become consultants. We plan to convert 40 FTTA posts into ST3+ posts over transition so that we increase our output of CCT holders in O&G.

31. Workforce Issues- In Summary Organisational culture � leadership, flexible and multi-professional working Overall, skills and knowledge rather than roles need to be looked at from an early stage. This emphasis may lead to the development of new roles and ways of working. Education and development Return to midwifery practice Improving working lives including practice models and skills mix Changing the Culture- leadership and team working. Imperatives such as the choice agenda and the EWTD are compounded by significant issues with recruitment and retention in the midwifery workforce. The Required Skills, Knowledge and Competency Levels To truly design a new service for the future, new skills around offering choice and assessing complex information will also need to be looked at. Overall, skills and knowledge rather than roles need to be looked at from an early stage. This emphasis may lead to the development of new roles and ways of working. Education and Development There is a need to look at increased staff retention and improving training routes with a range of workforce supply strategies to support the recruitment and retention of midwives. To review and make recommendations to improve the education process and the education product to see if it is fit for purpose and workforce data being collected across HEIs to help manage future risks. There is a need to have a maternity workforce that can effectively locally deliver the Children�s NSF, as well as commitments to choice in the 2005 Manifesto, Health White Paper and relevant PSA targets. To look at increasing training commissions to maintain existing supply whilst having an increase in part time workers. Return to Midwifery Practice Validation exercise undertaken to assess impact of any return to practiceChanging the Culture- leadership and team working. Imperatives such as the choice agenda and the EWTD are compounded by significant issues with recruitment and retention in the midwifery workforce. The Required Skills, Knowledge and Competency Levels To truly design a new service for the future, new skills around offering choice and assessing complex information will also need to be looked at. Overall, skills and knowledge rather than roles need to be looked at from an early stage. This emphasis may lead to the development of new roles and ways of working. Education and Development There is a need to look at increased staff retention and improving training routes with a range of workforce supply strategies to support the recruitment and retention of midwives. To review and make recommendations to improve the education process and the education product to see if it is fit for purpose and workforce data being collected across HEIs to help manage future risks. There is a need to have a maternity workforce that can effectively locally deliver the Children�s NSF, as well as commitments to choice in the 2005 Manifesto, Health White Paper and relevant PSA targets. To look at increasing training commissions to maintain existing supply whilst having an increase in part time workers. Return to Midwifery Practice Validation exercise undertaken to assess impact of any return to practice

32. Summary & Next Steps Peter Blythin Director of Nursing and Workforce Development

33. Thoughts from Today Lots of enthusiasm. Wealth of expertise and examples of good practice. The need for local vision around maternity services. Importance of user involvement, clinical leadership and multidisciplinary working. Areas are at different stages of development for implementation & there are specific local challenges. Workforce solutions/skill mix to increase workforce capacity. Development of multi-agency care pathways.

34. Next Steps � From Today NHS West Midlands is working in partnership with CSIP, GOWM and NWP. Record discussions and ensure all materials on line. Local implementation arrangements. Joint regional action plan for children young people and families. All materials available on line on the CSIP/NWP website Support tools - NWP workforce planning resource pack; E-learning - 6 Steps and web portal. Joint regional action plan for children young people and families. All materials available on line on the CSIP/NWP website Support tools - NWP workforce planning resource pack; E-learning - 6 Steps and web portal.

35. Next Steps � NHSWM - Geographical based action learning sets around workforce planning. CSIP to support implementation of the maternity toolkit, the MM Self Assessment Tool and working within the patch to decide the best way on how we will deliver on this. West Midlands Maternity Matters Implementation Board. Directors of Commissioning meeting. NHSWM supporting geographical based action learning sets around workforce planning. CSIP to support implementation of the maternity toolkit, the Maternity Matters Self Assessment Matrix and working within the patch to decide the best way on how we will deliver on this. Clarity on local structural process as the mechanism for delivery rather than being highly prescriptive. At the very least it will be around being clear about the structure, process and what people locally are going to use to implement Maternity Matters. What we expect the local structure to be� don�t leave any stakeholders out Credible processes, work programme is realistic and able to deliver the outputs Maternity matters is a commissioners led process looking at issues. West Midlands Maternity Matters Implementation Board. If you have any thoughts on who should be involved and what specific areas it needs to focus on initially contact me at Peter.Blythin@westmidlands.nhs.uk Directors of Commissioning meeting NHSWM supporting geographical based action learning sets around workforce planning. CSIP to support implementation of the maternity toolkit, the Maternity Matters Self Assessment Matrix and working within the patch to decide the best way on how we will deliver on this. Clarity on local structural process as the mechanism for delivery rather than being highly prescriptive. At the very least it will be around being clear about the structure, process and what people locally are going to use to implement Maternity Matters. What we expect the local structure to be� don�t leave any stakeholders out Credible processes, work programme is realistic and able to deliver the outputs Maternity matters is a commissioners led process looking at issues. West Midlands Maternity Matters Implementation Board. If you have any thoughts on who should be involved and what specific areas it needs to focus on initially contact me at Peter.Blythin@westmidlands.nhs.uk Directors of Commissioning meeting