Continuity and consultation

Having been an independent midwife for several years of my midwifery career, I, for one, did not have to be convinced of the benefits of Continuity of Carer (CoC) for both mother and midwife. The publication of the National Maternity Review and its endorsements of CoC were greeted with open arms (NHS England, 2016). However, it must be appreciated that this was not necessarily the reaction from all midwives, as, for many, it called for a change in working patterns that some midwives had grown accustomed to for many years.

The London North West Local Maternity System (LMS) is committed to delivering the Better Births (NHS England, 2017a; 2017b) vision, developing and implementing new models of care across the sector (Box 1). Our aim is to provide all women with a named midwife throughout their pregnancy journey. We are committed to providing every woman and her baby or babies with the best start, providing safe high-quality integrated care, through information sharing and support for the promotion of healthy lives.

Box 1.Advantages of the ‘Better Births’ continuity of carer plan

• Facilitates consistency in midwife or clinical team, providing hands-on care during pregnancy, labour and the postnatal period
• Enables co-ordination of a woman's care, as a named individual is responsible for ensuring the needs of the woman and her baby are met in the right time and place
• Enables the relationship between the woman and the person caring for her to develop over time

Our vision as a senior management team linked to the theory of change to enable sustainability. The initial reaction to the suggestion of providing CoC was received with great negativity. Senior team members and staff stated that the majority were quite happy and there was no real appetite for changing the status quo. Frankly, midwives did not want to work in this manner.

Despite being given all the evidence, there was still much scepticism within much of the workforce in relation to their understanding and willingness to provide CoC (Taylor et al, 2018). Therefore, it was recognised that there had to be a bold realignment of service provision to achieve the gold standard of each woman being given a named midwife. Utilising the current workforce to redesign how and where we could provide CoC, providing more quality outcomes with the same workforce.

‘Our vision as a senior management team linked to the theory of change to enable sustainability’

To begin with, I sent out an email to all midwives, seeking transformational champions to be a part of the reinvigoration of maternity services within our trust. I met with several on a one-to-one basis, to explain what was being proposed, as well as gaining essential insight from their perspective on how they would like to work. It was clear that many midwives within the unit were not ready to provide 24/7 on-call services at this point. However, they did seek to have more meaningful relationships with the women they provided care for. In other words, they were happy to have a caseload through working traditional shift patterns, as it was felt this would not impact negatively on their family–work life balance. Personally, I found the complete opposite was true when being a caseload midwife at St. Thomas' with a young family. However, you have to accept each individual's reality. Nevertheless, the response confirmed my faith in midwifery, and a small team of six midwives created our first caseload team.

So, we started with six enthusiastic midwives based in our birth centre, with a caseload of 60 women per midwife. Each midwife had a set clinic day for their antenatal and postnatal mothers. Initially, women were transferred to the team from 28 weeks, as they undertook booking their women to build up their caseload. The team also ran their own parent craft classes, where other mothers could attend, and coffee mornings that postnatal and antenatal mothers could attend. This facilitated networking for mums and allowed them to have a social support system beyond our package of care. It also enabled women to meet the team, in addition to a team biography folder, with the aim that the women would know the midwife caring for her in labour.

As anticipated, when achieved, this went well for both the women and the midwives; the women were more satisfied with their care and the midwives were experiencing greater job satisfaction. However, we recognised this was a small group of mostly exclusively low-risk women. To achieve CoC on a wider scale, a reconfiguration of our maternity service would be required, influencing our operations to deliver the ambition of true transformation. This was a tall task within a unit with limited resources, but our vision was an opportunity to rewrite our narrative and provide a safe, high-quality maternity service, through the provision of continuity (NHS England, 2016) and individualised care. This would improve clinical outcomes and the experience for the women and families who we care for.

We had to accept the process would be long and challenging, as this was to be a whole system change to achieve a workforce model that was fit for purpose, so it was important that we fully understood our current system. We had to identify inefficiencies and recognise opportunities in working practice, which included reviewing all midwifery working contracts. Therefore, processes were mapped, our service data collected and analysed, and user views were gathered to determine how our service could be improved and sustained. The importance of getting the women's voices heard was at the forefront of our mind for partnership working and taking an ecological model to birth (Schmid, 2014). We went to our local children's centres and set up listening events, so women and their families had the opportunity to provide their feedback. It was also useful for recruiting to our Maternity Voices Partnership.

The review used standard methodology:

The divisional lead took the five-step improvement approach (NHS Improving Quality, 2014), aligning to local and national objectives (Box 2).

Box 2.The 5-step improvement approach

• Preparation: defining aims and objectives, scoping of baseline
• Launch: communication plans in place and shared
• Diagnosis: external review to understand current situation
• Implementation: utilising Plan-Do-Study-Act
• Evaluation: celebrating achievements, continually reviewing, learning
• Meet with the service
• Compile information on the current service
• Compare with best practice guidance
• Make recommendation
• Review draft with the senior management team
• Present final review to chief nurse.

To prepare, we had to gain understanding of our background, which created our present culture, from all aspects of our service. To ensure the review of our service was unbiased, our community service was reviewed by an external consultant midwife and head of midwifery, together with our deputy divisional lead and myself. Our community was an essential part of the service review required, with a workforce that was challenged by many members who were unable to cover on-calls for various reasons. This had a direct impact upon a woman's choice, home births and the provision of CoC. Hence, the terms of reference for the community review were set up, including trained, untrained and admin members.

The aspirations set out by Better Births provided a clear and accurate definition of what was to be achieved. Thus, the consultation was put forward, and listening events with the whole team were held. Changing established systems can be challenging. Fostering an environment that is conducive to listening to the rationale for change was essential, particularly as we faced a deeply embedded culture within the unit that was adverse to change.

It is vital to get the whole team involved, and allow them to express their reservations and experience. Therefore, a multitude of group events and/or one-to-one sessions were held with the senior team, allowing us to share a clear vision and the reasoning for the need for change. Through team involvement, a clear platform was established to undertake the next step.

The consultation from the maternity workforce and from women across the LMS found three preferred models (Box 3). The evidence suggests CoC could play a major part in reducing health expenditure, and this will be evident in the long run (Freeman and Hughes, 2010; Ford, 2013; Sandell, 2018), but our primary focus is to achieve safe, high-quality midwifery care with positive outcomes for both women and staff (NHS, 2015).

Box 3.London North West Models of Continuity of Carer

It is now widely recognised that vulnerable, socially disadvantaged women and those from Black, Asian and minority ethnic (BAME) groups are more likely to have poor outcomes, for both mother and baby, in relation to their white counterparts (Knight et al, 2019). Therefore, these are groups that should be prioritised to receive CoC. We recognised this to be an essential aspect, but we did not want to place a social stigma or label on these groups, as these are recognised factors that contribute to disengagement and social exclusion, the opposite of what we were trying to achieve (Chappell, 2016). This reconfiguration provided an additional opportunity to achieve the goal of 75% of socially disadvantaged and BAME women being provided with CoC, by having all of our community teams provide this service. Therefore, BAME women or those in socially vulnerable groups would not be identified either through their postcode, ethnic background or social economic status. They would also not be differentiated by the team, as the same model of care is provided to all.

We had the brave aspiration of achieving more than 50% of women being on the continuity pathway by March 2020, to provide women and their families with the best evidence-based care for better outcomes both physically and psychologically.

Once the consultation period was over, the new landscape consisted of a reformed maternity service, focused on the provision of CoC, with a community service who all provided CoC, a birth centre who all carry their own caseload, as well as an elective caesarean section CoC team, a CoC safeguarding team and two high-risk CoC teams. Our percentages have been impressive – over our aspiration of 50% – the task now is to ensure women receive the whole package.

Challenges to sustainability of the model also cannot be overlooked, with a transient workforce, high vacancy rate and a unit with limited resources. As a result of unit-specific issues, providing midwives with uplifts in pay was not an option, as has been implemented in other financially able units. Other challenges and barriers are the result of vacancies. Bank (temporary staffing) and agencies fill shifts, which reduces the ability for all women to be facilitated in birth by their named midwife or team.

Gaining our stride in the provision of CoC appeared to be unbalanced by the COVID-19 pandemic. Witnessing the devastating human cost from COVID-19 created an environment of heightened anxiety and fear from the general public, as well as healthcare professionals (Royal College of Obstetricians and Gynaecologists and Royal College of Midwives, 2020). Many changes were implemented to maternity care provision, with the aim of containing the virus and protecting the health and wellbeing of the women and their families, as well as the staff and their families. Staffing numbers and teams were also impacted by members having to shield. Initially our phone lines within the unit were inundated with women and their partners, who were concerned with how this virus would impact their care.

Box 4.Barriers to continuity of carer

• Fear of burnout
• Travel - many not living within the local area
• Impact on social-family life
• Lack of structure
• Salary
• Loss of weekly days off (when working a 12 hour shift)

The benefits of CoC were clearly visible in this time of crisis. Women who had received CoC were more assured that there would be no negative effect on the care they would receive. Many who received CoC fed back that this was the case. I feel that this provides further evidence of the value and importance of implementing CoC in these uncertain times within maternity services.