Maternity fight: How are plans to save Cumbria's services taking shape?

At the time bosses said the change was saving lives, but agreed to do more in future to engage with local people and ease growing tensions.

Yet efforts were hampered recently when controversial plans - drawn up by the Government-appointed Success Regime - to remove consultant-led maternity from the West Cumberland Hospital came to light.

Following major opposition, local NHS leaders agreed to give the service a one-year reprieve to tackle long-standing recruitment issues.

However most significantly, they vowed to adopt a new approach - dubbed "co-production" - which would see them sit down with communities and work on a solution to these high-profile problems together.

Some were optimistic, many others were skeptical. Almost a year on from NHS Cumbria Clinical Commissioning Group's (CCG) decision and the clock has yet to start formally ticking on maternity.

Yet the CCG has lived up to its promise, forming the Working Together group as a forum for co-production to get underway.

It has been meeting every month since June, getting health leaders, community representatives and hospital staff around a table to have honest conversations about the issues facing west Cumbria.

Those involved say it is still early days and they are still a long way from finding all of the answers. However for the first time there is hope of a new approach, that the community's voice has been heard.

For many the jury is still out, and it will remain there until they see consultant-led maternity secured long term.

Richard Pratt, the Archdeacon of West Cumberland, is among the optimists. He was appointed independent chairman of the group, having previously chaired the West Cumbria Community Forum.

He said it was clear that if consultant-led maternity in Whitehaven was to be maintained, lots of people needed to come together and help tackle the recruitment issues that have left it vulnerable.

"It seems to me that if these things were easily solved, they would have been years ago. It is only by getting everyone round the table, working together and being patient that it can happen," he said.

Rev Pratt said that with many in the community feeling "bruised", it wasn't an easy conversation to start. But his job was to remain neutral and facilitate those difficult discussions.

"If you take an opinion about something you can end up promoting that, but the job of the chair is to make sure other people get time to share their points of view. It's about making space for both sides," he said.

"We've had several meetings. Some have been tougher than others, but I think people have been able to speak their mind and we are beginning to see some definite forward movement."

He firmly believes that the only way for west Cumbria to get what it wants, is to lead the way. Instead of shouting from the sidelines, the community can look at the barriers and find ways around them.

"Instead of waiting for someone else to sort out our problems, we are going to take part. Nobody is going to come over the horizon with the cavalry. We have got to solve our own problems," he said.

"Also there are things that the NHS can and should do, but there are others that it can't. If people are going to come to Cumbria, then they have got to be made welcome. They need schools, housing, friends.. that's where the wider community can really help.

"We need to be pushing ourselves, saying this is a great place to live and thinking of all the positives."

The meetings are attended by all sorts of people - from health campaigners to senior NHS executives, maternity and paediatrics staff to local councillors. There is also input from Healthwatch, various community groups and other interested individuals.

They are split into five sub groups, looking at maternity, paediatrics, recruitment/retention, care at a distance and telemedicine. Each meets separately and reports back to the monthly meetings, meaning they can look in more depth at each of the issues.

Sandra Guise was part of the Maternity Services Liaison Committee (MSLC) that raised serious concerns about the plans to transfer consultant-led maternity. That has now merged into the new Maternity Voices Partnership, aiming to bring the views of local women to the fore.

Asked for her view on co-production, she said that is what her group has been trying to do for years. "In a sense we already worked in that way. We gather feedback listen to individuals and work together to influence services. We were, in a sense, leading the way," she said.

"The Maternity Voices Partnership is part of the national Better Births plan, giving service users a voice at the table early in the decision-making process. It means having a better, less paternalistic health service and instead empowering people. It's their baby and their choice."

She said that even under the current option, some higher risk pregnancies are still going to have to go to Carlisle. That is a concern as it removes the choice available to women. However she said they have to be involved in discussions, to ensure their voices are heard, make suggestions and ultimately reduce anxiety for pregnant women locally.

David Rogers, medical director at the CCG and a west Cumbrian GP by background, was among those who faced the angry crowds at the rugby club meeting back in 2014.

He this new era of co-production has been building up since then, and he hopes it will help to rebuild the trust.

"It is still far from finished but I think we have seen a lot of progress. It takes time and we have to work at it, but I'm pleased with the progress that's been made," he said.

"A lot of it is actually about sitting down with people and involving them. It's really important to have that perspective.

"It is only by being open and transparent, involving people and gaining that trust, that you will see those improvements.

"I do think it's improving. The challenge is how you get that across to more people. There are people that are committed and devote a lot of time, it's how you then feed that back to different networks, so that people know they can get involved and make a difference.

"We won't always agree on everything, but it's about understanding each other's issues and coming up with the best solution together. We are determined to make this a part of how we do things.

"A formal NHS consultation is a specific process. This is different. It is about engaging with people and working with them all the time. It is about continuous improvements and little changes."

He stressed this is not just a one-off gesture to appease the community.

"It needs to be embedded. In future, if we are going to do anything on maternity the automatic position should be to involve the Maternity Voices group from the start, not come up with a plan and then speak to them about it," added Dr Rogers.

Sue Stevenson, chief operations officer at Healthwatch Cumbria, is there to ensure patients across the county have a voice.

She said NHS England has just commissioned a piece of research into co-production in Cumbria, which could be used to help shape similar conversations on health services in other areas.

She explained: "The word coproduction seems to be in everything I read at the moment. We are doing it rather well in Cumbria. We are at the forefront. Our reflection is that it can be quite tricky, quite painful, can test relationships and push people's buttons.

"Going back to that big meeting at the rugby ground, it was very obvious that things weren't right. The West Cumbria Community Forum was put in place to try and foster relations.

"The CCG asked for more co-production to take place. It's not always a smooth path. It's not about just talking and everything will be better, but it's creating an opportunity for negotiation."

Although pleased with how the process is now taking shape, she is keen to expand its reach to the wider community, to ensure even more voices are heard, not just those attending meetings.

Ali Atkinson-Budd is the new associate director of midwifery at North Cumbria University Hospitals NHS Trust. She previously worked for NHS Improvement, but said she has been impressed with the way co-production has been embraced in west Cumbria.

"The involvement from the community here is really strong. I've never experienced anything like it anywhere else. I think it's a real strength, to have the sort of input," she said.

"It's not just the community but the staff as well. They've been through a really turbulent couple of years with the consultation and uncertainty that surrounded that, but the passion they have is clear. They are just so determined to make it work."

*The next meeting of the Working Together Steering Group takes place on Wednesday, February 28 at Allerdale House, Workington. To find out more visit www.northcumbriaccg.nhs.uk

It is not only maternity services that are the subject of co-production.

It was actually Cumbria's community hospital campaigners that set the ball rolling, deciding that rather than simply protest against bed closures they had to come up with potential alternatives.

The groups in Maryport, Wigton and Alston have been working tirelessly, supported by leaders at the Cumbria Partnership NHS Foundation Trust, since before the Success Regime consultation began.

Their draft alternative plans were well-received by CCG bosses, and it inspired a similar approach for maternity.

Although the hospitals in those three communities are still set to lose their beds, the plans - which have yet to be approved - have come up with innovative ways to allow people to be cared for in their local area wherever possible. For example, in Wigton they hope to use NHS-funded beds at the town's Inglewood care home.

Eveline Dugdale, of the Joint League of Friends, is hopeful that these plans will now get the backing of the CCG.

Having twice fought a campaign to save community hospitals, she firmly believes that had they not started conversations with hospital bosses they would have lost all of the area's beds.

Although some are still closing, she believes the alternatives are the best possible compromise "We are not there yet but we feel we are succeeding. We think we are," she said.

What is coproduction?

• "Co-production" effectively means working together.
• The phrase was coined by NHS chiefs to explain how they want to work alongside local people to develop services.
• It is not a formal NHS consultation, which asks for input on specific major service changes and reconfigurations.
• The aim is to open up a conversation that can help influence how services are developed to meet local needs.
• In Cumbria, the NHS has set up the Working Together Group to focus on maternity and other services in west Cumbria, as well as groups in areas set to lose their community hospital beds.
  
• Work to date includes promoting the area as a good place to live and work to attract new staff, and using local knowledge to redesign community services so more people can stay out of hospital.