Since the introduction of Better births in 2016 there has been an ongoing plan to transform maternity services with the roll out of Midwifery Continuity of Carer. Professor Trixie McAree: National Lead for Midwifery Continuity of Carer, National Clinical Advisor (midwifery) for choice and personalisation, addresses in this article some of the essentials and pitfalls of developing these changes.
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In the series of articles and talks for the Maternity and Midwifery festivals we have spoken about the evidence behind, and the imperative for change. We understand that to avoid the repeated cycle of poor reports and clinical outcomes we need to introduce a new way of working. This, of course is providing Midwifery Continuity of Carer (MCoC) as the default position for all women. However, this is a complex, large-scale change which is notoriously difficult to implement. This article will discuss some of the pitfalls to avoid and some nuts and bolts to have in place that will support successful roll out of MCoC.
The October 2021 NHS England » Delivering Midwifery Continuity of Carer at full scale: Guidance on planning, implementation and monitoring 2021/22 sets out details for MCoC teams and includes a list of building blocks that need to be in place in order to implement MCoC safely. These are, you could say, the nuts and bolts, the building blocks that form the basis of your implementation plan. Not having a plan is the biggest pitfall that maternity serivces can fall into, as it is likely to lead to disallusionment and disappointment for staff as teams may be unsustainable.
If you wanted to be the first midwife to climb Everest you could not just fly to Nepal and do it. You would most likely be unsuccessful. It may take you 2 or 3 years to plan. Implementing MCoC, likewise needs careful planning even before the first teams are rolled out to ensure they have everything they need in order to be safe and sustainable. In Autumn NHS England will be releasing ten e-learning modules about the building blocks that need to be inplace and how to use them to support roll out of teams. These building blocks are by no means exhaustive but they will ensure you cover off all the key areas where foundations need to be in place for this model of care.
When thinking about introducing large-scale change our first consideration should be our minds. Einstein is often quoted as saying that “insantify is doing the same things over and over again but expecting different results” yet often this is what we are often guilty of. Transformation, by nature needs ot be radical. Here is nothing about a caterpillar that tells you it is going to be a butterfly. We need to think big and out of the box, rather than shoe horning a new idea into an old groove.
In planning to have all the nuts and bolts in place you have to think about what parts of your service will be affected by the change and make sure mitigation or approprote actions are taken to ensure there are not adverse effects. Changes include:
- Change the way women experience care
- Change clinical outcomes
- Change the way how staff deliver care including where we work
- Change the way we staff our units
- Change how we operate as a team and are accountable
- Change the way the MDT works
- Change our Standard Operating Policies
- Change how some staff are paid
- Change the way we report and provide oversight
This article will look at the three elements in bold, others will be reviewed in further articles.
Safe Staffing
The pitfall: to avoid is not in describing your current staffing, who you have against what you need, where they work, how many you need to recruit and how would you safely deploy them into MCoC teams.
If you don’t have enough staff, quality of care is adversely affected regardless of model of care. When considering the appropriate time to start rollout of MCoC you must weigh up the benefits of MCoC – such as improved clinical outcomes – against any impact on the rest of your service. The NHS E deployment tool will help you do this and help you describe and document your conclusions.
To support maternity services consider the staffing and deployment element of this change; NHS England commissioned a tool and accompanying resources to support and guide services to describe their current midwifery staffing position and consider how to safely deploy midwives for MCoC. It does not tell you what your establishment should be.
Development of the tool has been iterative, building on what many Directors (DoMs) and Heads of Midwifery (HoMs) shared about their staffing experience and service configuration. It has been heavily stakeholder driven and developed.
This tool supports planning for safe deployment but ultimately the final decision about whether staffing is safe, including numbers of midwives, division/ratios of midwives to other maternity staff e.g., maternity support workers (MSWs), nurses and nursery nurses where staff are deployed rests with maternity service leaders and their Trust boards.
The principles for its design have drawn from the following documents:
- Safe midwifery staffing for maternity settings (nice.org.uk)
- 2904770 NQB Guidance v1_2_with links A (england.nhs.uk)
- safe-staffing-maternity.pdf (england.nhs.uk)
The link for the tool is here: NHS England Maternity Workforce Deployment Tool – Maternity Local Transformation Hub – Maternity (future.nhs.uk). Accompanying the tool, a power point provides page by page instructions and explainations for use.
Autonomy and team building
The pitfall: not to prepare staff to work in a new autonmous and flexible way.
The MCoC team are responsible for their cohort of women, ensuring they receive all elements of care including appropriate referals. Between them they have to ensure someone is available for intrapartum care. This works out at being availble for one night in 6, not very different to working 3 to 4 night shifts a month but arguably more pleasant. The teams need to work these details out them selves but it should be said that work can be planned well inadvance to ensure there is cover for child care for example, and ensuring a good work life balance.
The live case load is 1:27 average, therefore midwives need to think differently about how they arrange their diaries. They can pursue clinical excellence – safety, choice and personalisation as well as creative caring and community building.
When putting teams together consideration needs to be given to how the teams will interact together. This means looking at playing to their strengths as well as learning to operate as the optimal team avoiding the pitfalls set out by Lencioni (2005) in his “Five (dys) functions of a team Five Dysfunctions of a Team by Patrick Lencioni – Bing video
Teamworking with a common purpose, professionalism, compassion and listening were all identified as areas which require strengthening in maternity services according to Reading the Signals: Maternity and Neonatal Services in East Kent. The Report of the Independent Investigation published in 2022. Paying attention to this important facet therefore will bring the best out in the MCoC teams.
Importance of the Multi-Disciplinary Team
The pitfall: Not involving obstetricians from the beginning.
MCoC is not only about midwives, it is about the entire maternity service coming together and are reorganised to provide this evidence-based intervention.
All Midwifery Continuity of Carer (MCoC) teams should have a named linked obstetrician with whom they have a clear relationship.
The benefits of this approach are:
- Women’s needs are assessed, and support offered accordingly, whilst maintaining the continuity of relationship. PCSP are agreed and written and executed all together.
- More efficient clinics as there will be potentially reduced footfall as better referral processes, which will be easier for women and clinicians.
- Obstetricians may have more time with women they really need to see thus more time for teaching their teams
- Develop multi-professional team approach with midwives and opportunities for teaching and training.
- Midwives have more accessible relationship with obstetricians
Consideration needs to be given to developing their own way of working together. They need to agree:
- hold team meetings (including MDT for clinical care, as necessary),
- make contact for ad hoc advice.
- discuss specific cases.
- How best to utilise digital capability to enhance communication.
The MCoC team is a microcosm of good clinical governance. They will meet regularly to discuss their team cohort metrics, cases, incidents, complaints, and compliments. The linked obstetrician will be part of this regular review. This team level approach will feed into the wider departmental and directorate governance process and ultimately up to executive boards.
The teams will have two approaches to working with their obstetricians:
The most common will be mixed risk geographical teams. Here women enter the service, are seen in their local children’s centre or similar, close to home. However, where a risk becomes apparent midwives liaise with their linked obstetrician to make a plan and carry it out.
The second is where women have complex medical needs which are obvious from the booking/referral letter and will probably require significant medical input. For these women, an audit should be undertaken to understand how many women and what kind of need, may be placed into “maternal medicine” MCoC teams. These women would be most likely cared for at a hospital-based antenatal clinic.
In this article we have discuss the importance of thinking differently, planning and looking into a some of detailed facets of that process. The key to implementing change is to have a robust plan that identifies current position and the process by which you mean to move forwards. In working with this we will avoid many of the pitfalls and ensure that we get all our nuts and bolts in place before setting off on our transformation journey.
Professor Trixie McAree:
National Lead for Midwifery Continuity of Carer, National Clinical Advisor (midwifery) for choice and personalisation.
July 2023