Maternity Strategy
2010 – 2015
“The Best Possible Start in Life”
For Board Approval
December 2010
Our shared vision is one where
all maternity related services and
communities work closely together to
support women and families
to give their children
“the best possible start in life”.
This strategy is also available in large print and other
formats and languages, upon request. Please call NHS
Grampian Corporate Communications on 01224 551116
or (01224) 552245.
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Contents
1
Executive Summary .................................................................................... 3
2
Driver Diagram ............................................................................................ 5
3
Introduction ................................................................................................. 6
4
Vision .......................................................................................................... 8
5
Key Improvements ...................................................................................... 8
6
Improvement Targets .................................................................................. 9
7
Service and Community Changes ............................................................. 10
8
9
7.1
Delivering Holistic and Integrated Lifestyle Support ........................... 10
7.2
More Consistent Skills, Flexible Workforce and a Robust Service ..... 10
7.3
Better Confidence and Skills for Normal Births .................................. 11
7.4
Supporting a Nurturing Environment .................................................. 11
7.5
Developing a More Responsive Service ............................................ 11
Supporting Improvements ......................................................................... 12
8.1
Reducing Waste & Unnecessary Variation and Improving Standards 12
8.2
Designing Capacity for Increasing Births ........................................... 13
8.3
Improving Information Management................................................... 13
8.4
Developing Communities ................................................................... 14
Implementation and Evaluation ................................................................. 15
Appendix 1 – Maternity Services Strategic Review Leadership Group ............. 16
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1
Executive Summary
Why this strategy is needed
Our existing maternity strategy expires in 2010. The challenges and goals for
maternity services have moved on significantly since it was written. This
strategy lays out the new challenges and goals clearly, as well as the changes
we will make to meet them. Most importantly it lays out our shared vision of all
maternity related services, agencies and communities working together to
support women and families to give their children the best possible start in life.
How we got here
Whilst reviewing maternity services, we sought the views of hundreds of women
and families who were using or had recently used our services. We talked to
many staff, partner agencies and community groups about their views of what
needs to improve. This and much other information was collated for an event in
August 2010 at which staff and women from across Grampian agreed a wide
range of goals and actions to deliver them. We used that information as the
basis for this strategy, then consulted with the public, all of which shows the
wide range of people who helped to create it. The members of the Maternity
Review Leadership Group which oversees the process are listed at Appendix 1.
The state of our current services
Our maternity and related services, from community to hospital, provide high
quality care every day, hand in hand with our partner agencies. They do this
with commitment and dedication despite rising workloads and expectations and
we value them highly for this. Equally, women and their families are well
supported by communities before, during and after pregnancy and we are
grateful for this on many levels. All staff strive to deliver the best service and
support possible, and to improve every day. This is the case whether supporting
the joy of a healthy baby’s birth, or the tragedy of pregnancy loss.
What this strategy does and does not do
This strategy does not lay out all the improvements in hand or, planned. It lays
out for the people we serve, the staff we employ and the partners we work with:
 the biggest improvements we will make over the next five years
 why those improvements are important,
 the challenges to achieving them, and the solutions which will help,
 our vision which co-ordinates and drives our efforts in the same direction.
The direction of travel
That direction is towards the bigger, vital contribution we will make together, to
reduce the difference in health between the richest and poorest people. Every
step from before conception to loving and nurturing a growing, healthy child
plays its part, and maternity services will lead in helping each part be positive.
Key examples include:
 supporting healthier lifestyles and better well being
 returning to the position where normal births and breastfeeding are the
expectation,
 interventions such as caesarean section and formula milk only being
chosen when necessary.
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The sorts of changes needed
To deliver these changes we will improve the way we involve front line staff in
planning, designing and implementing them. We and our partners will also be
more active in seeking additional help from communities to support women and
families in their choices. Equally some roles are currently seen as needing
health professionals but are actually the natural role of communities if supported
by public bodies, and the third sector (charitable, voluntary, non government
etc). We will support communities to take these on, and redirect our efforts
towards being more effective and improving our ability to improve the health of
the worst off. For the core roles we retain, we will move to a model of staff
development and deployment which is more flexible, fair and which keeps a
wider range of specialist and general skills up to date. This will ensure a more
integrated service across all areas, including for example General Practice, as
well as those dedicated specifically to maternity care.
Challenges to delivering change
These changes will not be easy for a variety of reasons. They are in addition to
running safe, affordable services. In our current financial climate there is no
prospect of additional funding so the focus will be on implementing them entirely
within the resources available. That will mean difficult decisions about
prioritising existing resources and effort. They require big cultural changes to
the way we work and the way we interact with partner agencies and
communities. Crucially we need to support women and families to make choices
in line with these changes, but through listening, and without making women
and families who make other choices feel stigmatised.
Similarly though, views of some people in our communities need to change and
this will be challenging. The consultation on this strategy revealed for example
that some people firmly believe that bottle feeding is as healthy as
breastfeeding and that choosing between them is simply a matter of preference.
Solutions to delivering change
For all these reasons, the changes will need strong leadership and capacity to
be released. This effort will be led across NHS Grampian by a single
management team. They will co-ordinate with related services, partners and
communities. Capacity will primarily be found by reducing waste, inflexibility and
unnecessary variation whilst improving standards. These efforts will be guided
by the systematic and rigorous use of “Continuous Service Improvement” tools.
Capacity will also be found by assessing the overall configuration of our
services to ensure they are able to deal with our rising birth rate, its local
variations, and other challenges. We will also make better use of technology to
improve the way we capture, use and share information. This applies to
information used internally, and to information we provide to women, families
and communities to help them make the best choices. Together these are the
choices which we can all make to help give children “the best possible start in
life”.
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2 Driver Diagram
The driver diagram below shows a high level summary of the changes we commit to in this strategy, some of the measures we
will use, how they relate to each other and their contribution to the longer term aims. These are not the only changes needed
to bring about the wider improvements, but they are the critical contributions that maternity and related services need to make.
Vision
Key Improvements
Service and Community
Changes
Supporting Changes
Reducing Waste
“The best
possible start
in life”
Healthier lifestyles and
confident parents
(less smoking)
Safer births
(more normal births)
Healthier babies
(Higher birth weights)
More nurtured children
(More breastfeeding)
Holistic integrated
support networks
Reducing Variation
Consistent skills,
flexible workforce
Improving Standards
Confidence and skills
for normal birth
Designing Capacity
Integrated risk
assessment and support
Responsive and
involving services
Improving Information
Management
Community
Development
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3 Introduction
Maternity and related services are arguably unique in health care in their
potential to improve both the health of women using them now, and of wider
society for generations to come. Vulnerable people and those in poorer
communities have babies with the same inherent potential as those that are
richer, but children from these backgrounds often fair worse in life than those
from richer areas. There are many reasons for this as shown in Diagram 1,
which shows causes of variations in health outcomes. Some causes can be
controlled by the choices individuals and families make, but crucially many
cannot, which is why this agenda is about more than choice, important as that
is. A key factor is the long-term stress which poorer people experience, and
their consequent lack of resilience to external causes.
Diagram 1: Causes of variations in health outcomes (from the World Health
Organisation)
Influencing health at every opportunity
We can do much to limit these problems not just by continuing to improve care,
but by working with partners and communities to influence other causes of
health outcomes at every opportunity. The most obvious opportunity is that by
giving children “the best possible start in life”, we give them the best chance to
minimise the effects of poverty.
Growing evidence now shows that to maximise health gain and reduce
inequalities in the population, the focus of all this effort must be on the health of
families before conception, during pregnancy and in the first three years of
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children’s lives. This is the most effective time at which improvements will not
just benefit parents but be passed on to their children and future generations.
Critical factors throughout these stages are women having healthy weight, good
mental health, and not smoking. People find it difficult to succeed in these areas
if their families are not also being pro-active. For example a person is less likely
to succeed in efforts to quit smoking or eat healthily if their family smoke or
have poor diet. This is why all agencies must think far more widely than about
the individual.
However, all agencies can provide even better support by involving
communities more in supporting whole families Most importantly, the more
communities see themselves as part of these solutions, the more likely they are
to tackle other problems, and hence increase their own resilience.
These are just some of the reasons that maternity and related services are well
placed to improve the health of the whole population for generations to come.
However, these services currently face many serious challenges which
significantly limit their ability to deliver this potential including:
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a trend towards unnecessary interventions in birth
perceptions in wider society about breastfeeding and other behaviours
our staff having wide variations in workload, rising workloads, rising
expectations, and finding it difficult to provide out of hours services
our service configuration and staffing models makes it difficult to cope
with rising birth rates
All services and communities must therefore act together decisively to:
 reverse the worrying trends
 design our services to better meet need; and
 support women and families at most risk to give all children an equal
chance of a long and healthy life.
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4
Vision
Our shared vision is one where
all maternity related services and
communities work closely together to
support women and families
to give their children
“the best possible start in life”.
In particular, we will move to a single, consistent but flexible service which
tailors support so that the families whose children are most at risk of poorer
health and wellbeing, can be helped to make choices that realise their true
potential. This means all families will receive care and support that meets
national standards, but those that are more vulnerable to poor health, and need
more support, will get it.
This is not just a vision of the safest, most effective and family centred maternity
service, although it is that; it is also a vision of families being nurtured primarily
by strong communities, supported, where necessary, by all public services and
partner agencies acting together to form a cohesive network of support.
5 Key Improvements
Whilst this vision may seem quite broad, maternity and all related services can
show leadership by supporting some very specific key improvements that will
help give children “the best possible start in life”. These are when all services
and communities together support far more women and families to:
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choose healthier lifestyles and have good mental health before,
throughout and after pregnancy
bond with their unborn babies during pregnancy
feel confident about pregnancy, labour, birth and becoming good parents
cope with any problems during those phases
have normal births in a safe, pleasant and supportive environment
have healthy babies at full term with normal weight
choose to exclusively breastfeed their babies for six months
nurture their growing children in a loving and supportive environment
Our staff already strive towards these goals and we value them highly for this.
But we know we can support them to do it better by helping them remove
obstacles.
Not all women and families will choose or be able to experience all of these
improvements. However if we succeed, these changes will become far more
common than they are now, especially in the most vulnerable families. They
should eventually become habits that are handed down across generations
universally. All our effort will be geared towards supporting these improvements
so that we can achieve this vision.
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6 Improvement Targets
To help deliver the above improvements, we aim for a range of service and
health improvement targets over the coming five year period. The most
important of these are as follows.
Halving the differences in smoking rates
Passive and active smoking during pregnancy harm both mothers and their
babies. Although there are many ways to have healthier pregnancies, reducing
smoking rates in families would improve overall health the most. In 2008, the
percentage of all women smoking when they started receiving maternity care in
Grampian was 20.3%, this is near the Scottish average of 19.2%. The good
news is that these figures are falling but there is considerable variation within all
NHS boards. 30% of women living in the poorest areas, and 38% of teenagers,
smoke at the start of their maternity care. In addition to our general smoking
reduction efforts, we aim to halve the difference in these figures so that worst
rates are much closer to the best.
From the lowest normal birth rate to the highest
Unnecessary interventions in labour and birth pose risks to mothers and babies,
both immediately and throughout life, and waste money and effort. Women in
Grampian have significantly fewer normal births (more interventions) than those
in other NHS Board areas, but there is considerable variation within our
hospitals. Dr Gray’s Hospital in Elgin consistently has the highest normal birth
rate of all consultant obstetric units in Scotland, with a 2008 figure of 69%,
whereas Aberdeen Maternity Hospital (AMH) had the lowest figure of 53%.
Although recent efforts at AMH have helped, the long term trend is that this
figure is falling (getting worse) as it is for most hospitals. Our target is that 70%
of births in Grampian will be normal by 2015.
Doubling the chance of normal birth weights
Babies born with low weight are at higher risk of ill health and death. For many
reasons, babies born to people living in the poorest areas of Grampian are 48%
more likely to have low birth weight. We aim to reduce that difference by half by
2015 so that the chances of babies from the poorest areas having a normal
birth weight will be much closer to the chances of babies in richer communities.
If babies having high birth weights this also leads to difficulties in later life.
There are far less of these than babies with low birth weight, but our efforts in
supporting women’s health must also help in this area.
From a third of babies breastfed to a half
The percentage of Grampian babies breastfed exclusively at six weeks was
37.9% in 2009 compared to a local target of 41.2% for 2010/11. These figures
are improving over time, but Northern Aberdeenshire and Moray had figures of
32.4% and 34.5% respectively. Our target is to increase exclusive breastfeeding
rates to 46% in all areas of Grampian by 2015.
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7 Service and Community Changes
To deliver the key improvements and the targets above, our services, partners
and communities will need to adapt and change.
7.1 Delivering Holistic and Integrated Lifestyle Support
Important as they are, we sometimes focus on a woman’s physical behaviours
and consequences, such as diet and obesity, in isolation. We do not take
enough account of environment, family behaviours, mental health and other
things which drive people to less healthy lifestyles and related problems like
teenage pregnancies. We also respond in a fragmented way: both by asking
individual staff to offer support which is not holistic, and by staff being unaware
of other contributions. Finally, we assume that too much support needs to be
delivered by professionals which can exclude and undermine communities.
We will support all staff to take time to think early about families as a whole,
supporting the most vulnerable people to tackle their physical and emotional
problems together. This support will be better co-ordinated, for example,
between primary and maternity care, as well as more anticipatory for example
supporting informed contraceptive choices and sexual health. It will also put
people in touch with community networks for support around aspects such as
mental health, and confidence in pregnancy, birth, and parenting.
Bonding with your baby is just as important as a
healthy physical lifestyle
Such support will cover emotional as well as physical aspects because how
women and families bond with their babies (during and after pregnancy) is just
as important to children’s future development as physical lifestyles. Involving
communities more actively in such support doesn’t just release professional
time and potentially deliver better support: communities that look after each
other can be more resilient to harm, and stronger in tackling other problems.
7.2 More Consistent Skills, Flexible Workforce and a Robust Service
Our staff are highly skilled and need continuing development and support to
learn new skills. However, we tend to promote staff concentrating in specific
areas or topics and do not ensure sufficient joint development across sectors
and agencies. Although local knowledge and specialism is useful and
appropriate, the rigidity that can come with it limits our ability to provide a
consistently high quality service overall. In addition, as birth rates have risen
and our population centres have changed, workloads have grown unevenly.
Improving staff morale
We will therefore work with our staff, partners and communities to use a better
model of joint training, development and deployment which:
 improves opportunity, fairness, working conditions and staff morale
 improves the quality and consistency of communication and support at
each stage of pregnancy and parenthood across different areas
 creates a more appropriate skill mix and keeps skills and allocation
flexible enough to provide a robust service across all areas.
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7.3 Better Confidence and Skills for Normal Births
Community staff already focus on supporting normal births but we will support
them to do this more consistently. Hospital staff inevitably focus more on
providing support for women with more complex problems, but even when
giving specialist care we will maintain our focus on supporting a normal birth.
Focus on supporting normal births
We will provide leadership, support and working methods that maintain access
to specialist services, but also promote the skills and confidence that support
normal births. Equally we will ensure staff communication skills, attitude and the
environment consistently promote the calm and comfort needed. We will also
support women and families to choose the carer and facility which is most likely
to provide the best outcome for them. However, choices about births (as with
many things such as breastfeeding) are heavily influenced by families,
communities and society at large. We will therefore do all we can to involve, and
influence views, more broadly than just at the time of pregnancy so that normal
birth and after care once more become the expected outcome.
7.4 Supporting a Nurturing Environment
The best possible start in life is about far more than how healthy babies are
when they are born. Maternity and other health services can influence many of
these wider aspects in line with the Scottish Government’s “Getting it right for
every child” approach. Being universal, maternity and primary care services are
in a good position to jointly see which children are more vulnerable to poorer
outcomes and can help reduce the risks of harm. We will improve our cultures,
systems and practice so that clinical and social risk assessment, sensitive
sharing of relevant information with our partners and provision of joint support
all come together seamlessly. More than avoiding harm, such approaches will
go further and positively help parents to develop the best practical skills in the
most loving and nurturing environment possible.
7.5 Developing a More Responsive Service
Whilst reviewing maternity services, and consulting on this strategy, we sought
the views of hundreds of women and families. Members of community groups
interested in maternity services are helping lead our review. We also discussed
our proposals with leaders of networks and partner agencies. All those views
have influenced both our improvement effort and this strategy significantly.
Women told us how important consistent advice and considerate support from
different members of staff are. They emphasised how much they value staff
who treat them with dignity, and have the attitude and confidence to support
everything from normal birth to pregnancy loss. We saw how important
community groups are to supporting the choices of those in most need, and
how we might work with them better. This approach of involving and working
with communities and acting on views from women and families will become the
routine culture of a more responsive and flexible maternity service. We will for
example take account of the wide range of different religions, faiths, spiritual
needs and cultures represented in Grampian, and continue to improve support
and access for non-English speaking families and those with disabilities.
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8 Supporting Improvements
Staff and communities throughout Grampian already strive towards many of the
aspirations laid out throughout this strategy, and the changes required to deliver
them. A number of those changes require support and permission from wider
organisations such as NHS Grampian and our partners: this section lays out
some of the most important ones.
8.1 Reducing Waste & Unnecessary Variation and Improving Standards
All public services know that in our current financial climate there is little
prospect of additional funding to recruit more staff or deliver the above changes.
We will therefore need to release time, effort and resources internally. As a
priority, we will support staff to remove waste, unnecessary variation and
improve standards. Staff often know about these problems and are frustrated by
them but need support to rectify them as they are so busy delivering services.
Examples of Waste
Sometimes community, primary care and unit staff repeat work because they do
not know it has been done elsewhere, or because they adhere to policies which
build in duplication needlessly. We will put support in place to ensure such
duplication is unnecessary and is removed. For example making sure we seek
information fully and correctly the first time, and then use it many times.
Examples of Unnecessary Variation
Information and policies have been developed across Grampian by many
different professional groups for different purposes without enough attention to
overall consistency. Similarly, many of our services have been set up
historically and separately. Together with changing birth numbers, this has
resulted in caseloads for midwifery staff which are far higher in some areas than
others. All these systemic variations are unfair on staff, on women and their
families and make it difficult for us to compare quality so we will remove them
without affecting the quality of individualised care.
Examples of Standards
The health service is a complex and large system and will always have risks.
Delivering care that meets national standards helps to minimise these risks. In
maternity care, examples include mothers experiencing complications such as
heavy blood loss, liver problems and needing intensive care. Although the most
recent national audit (of 2008) suggested that care was good in all Scottish
units, Aberdeen could still reduce these problems significantly to be lower than
the Scottish average. As a minimum we will therefore ensure we adhere to
standards which minimise these complications. Beyond this we will take a
wider view of contributory protective factors for example promoting more
involvement of General Practice in maternity care.
Support and tools to help staff do all this are available from our Continuous
Service Improvement programme. In addition, we will move to a single
management system across all maternity services to ensure consistency.
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8.2 Designing Capacity for Increasing Births
Births in Grampian have increased by around 25% over the last ten years to
over 6,000 per year. That rise is predicted to be even greater in future with
potential increases of 20% or more in the next five years to over 7,500 by 2015.
We must ensure our maternity services are configured to cope with this rise, the
large local variations within it, and deliver our aspirations laid out in this
strategy. We will therefore carry out an “Option Appraisal” to assess how our
maternity services are currently set up, looking at: what they provide, who
provides them and where they are located.
Through the Option Appraisal we will inform, engage and consult with staff and
the public about how services should be configured. We will initially explore all
the ways in which services could be provided. This will enable a wide number of
views to be considered and as full a picture as possible of the service to be
created. The most promising options will then be assessed by comparing their
benefits, risks and costs. All of these assessments will be transparent and
inclusive ensuring the reasons behind choosing a particular option can be
clearly seen. We will ensure we choose the model which, within the resources
available, is best value for money, i.e. the one which is best at delivering the
aims outlined throughout this strategy for least cost and risk. Specifically, the
model will:
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deliver the right care, in the right place at the right time by the right
person with the right skills
deliver high quality care which is as safe, efficient, sustainable and
affordable as possible
increase the chance of women and families making healthier lifestyle
choices, especially those with the worst health
maximise the number of normal births
facilitate holistic support integrated between services and communities
create a consistent network of care which tailors effort to need
provide care closer to homes and in the community, using specialist
hospitals only when necessary
take account of Grampian’s urban rural mix and associated transport
ensure our services are best placed to cope with variations in need
build in flexibility to cope with the rise in number of births predicted
8.3 Improving Information Management
The services we offer could be far more timely, efficient, and safe if we
improved our information management. This applies equally to:
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clinical information we capture, use and share to provide personal care
overall service usage and trend information for planning ahead
information we provide to women, families and communities
We are in the process of upgrading our core information systems and will
ensure these are tailored to deliver these benefits. We will also make sure
information we provide is consistent, and uses the best evidence on being
effective in influencing behaviours such as social marketing approaches.
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8.4 Developing Communities
Throughout this strategy we commit to developing a culture of working far more
closely with partners and communities to provide better, more integrated
support, especially to the most vulnerable people. Critically we will ask
communities to help deliver that support, not just comment on it. In return we
will help communities re-develop these skills.so that we are confident they are
safe and effective. Examples of better integration with, and use and support of
communities include:
 knowing which support groups, community bodies and voluntary
networks exist and treating them as valuable assets to be nurtured
 supporting the creation of these groups where there are gaps such as
geographic, social or topical
 signposting women and families to such groups potentially by including
people from them in antenatal classes
 encouraging other forms of volunteering and reciprocity in our services
and with groups
 working together earlier to become more preventive than reactive: from
schools shaping the views of children about healthy lifestyles, to the
media helping portray birth and breastfeeding as normal, to voluntary
groups preventing post natal depression in women by supporting those
at risk
 supporting local groups by running maternity services alongside them
 choosing locations where multiple services/facilities could come together
 encouraging more partners (of women) to feel included in maternity care
 delivering joint training for volunteers, community groups, other agencies
and NHS staff to promote consistency
 communities cascading training about healthy lifestyle choices
We will explore all of these and more. But this sort of approach is not just
suitable to maternity services, nor is it likely to work if only adopted by maternity
services. We have already set out this approach for all of NHS Grampian in the
Grampian Health Plan and we will continue to work with public and partners
through the Health and Care Framework to ensure this is a routine part of the
way we develop high quality, effective, sustainable and affordable services
which are responsive to the needs of the population.
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9 Implementation and Evaluation
This strategy poses many challenges to staff in maternity and related services,
to NHS Grampian as a whole, our partner agencies and the communities of
Grampian. It is a necessary and appropriate challenge which we will rise to
together to deliver the vision of giving our children the best possible start in life.
A good idea is only as good as its implementation;
people make it real in practice
The broad challenges, required improvements and types of solution are clear.
However many of the detailed solutions are appropriately left to be worked out
by those running and delivering services in partnership with those using them.
Showing our commitment, we have already provided support to develop this
detail at operational level. Plans are being drawn up now, have started to be
implemented and are already showing improvements.. In addition to existing
managerial and governance mechanisms, maternity services will produce
annual reports which show:
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what progress continues to be made against the action plans
the extent to which these have been successful
the progress towards the targets
the future year’s work required
evaluations of how successful each type of approach has been
These annual reports will be supplemented by monitoring and support to
develop a culture of continuous service improvement.
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Appendix 1 – Maternity Services Strategic Review Leadership Group
Members
Emma Ashman
Christine Bain
Elaine Brown
Lorna Campbell
Lena Crichton
Amanda Croft
Peter Danielian
Laura Dodds
Sandy Dustan
Susan Fraser
Jamie Hogg
Tracy Humphrey
Nikolaus Kau
Jane Knott
Neil Maclean
Fiona Marie
Lynn Marsland
Jean McConville
Jenny McNicol
Alan Pilkington
Nancy Robson
Kirsten Sawers
Elinor Smith
Jenna Storey
Pauline Strachan
Jim Tuckerman
Mary Vance
Paul Welford
Lesley Wilkie
Role
Service Change Adviser, Scottish Health Council
Unit Clinical Director, NHS Grampian
Service Planning Lead, NHS Grampian
Midwifery Manager, NHS Grampian
Consultant Obstetrician, NHS Grampian
Assistant General Manager, NHS Grampian
Consultant Obstetrician, NHS Grampian
Public Involvement Manager, NHS Grampian
CHP General Manager, NHS Grampian
Unit Operational Manager, NHS Grampian
CHP Clinical Lead, NHS Grampian
Consultant Midwife, NHS Grampian
Neonatology Clinical Lead, NHS Grampian
Midwifery Manager, NHS Grampian
Consultant Obstetrician, NHS Grampian
Aberdeen City Lay Representative
Deputy Director of Strategic Change, NHS Grampian
Midwifery Manager, NHS Grampian
Acting Head of Midwifery, NHS Grampian
General Manager, NHS Grampian
Moray Maternity Services Liaison Committee Chair
Staff Side Rep & Midwife, NHS Grampian
Director of Nursing and Quality, NHS Grampian
Aberdeenshire Lay Representative
Chief Operating Officer, NHS Grampian
GP, NHS Grampian
Local Supervising Authority Midwifery Officer, North of
Scotland LSA Consortium
Strategic Change Manager, NHS Grampian
Director of Public Health, NHS Grampian
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