RCM Response to HoM survey question on implementing Midwifery Continuity of Carer (MCOC)

By Mary Ross-Davie, Director for Scotland and Kate Brintworth, Head of Maternity Transformation on 17 December 2019 Maternity Transformation Midwifery Continuity of Carer - MCOC Survey

In June 2019, the RCM invited Heads of Midwifery across the UK to complete our annual survey. This year the survey included questions focussed on the implementation of Midwifery continuity of carer. The response rate for this year was higher than previous years, with 60% response rates (93 out of 156).

HoM responses to MCOC question

Of the 63 HOMs who responded about how easy it was to implement continuity 73% stated it was difficult or very difficult and 11% said that they had not attempted to implement continuity of carer. No Head of Midwifery stated it had been easy or very easy.

In terms of challenges that HoMs might face 62 HOMs responded. They were asked to select three from a range of possible issues. The top answer was 'staffing levels do not meet workforce analysis requirements' with 56%. The second, with 48%, was 'staff are unwilling to work in continuity models' and the third highest, with 37%, was 'lack of project management resources'.

Heads of Midwifery on their experiences so far in implementing MCOC:

"Have implemented but barriers to this are reorganisation of community workforce and challenges working within the restrictions of GP practices. Prior to moving towards the 35% there is a need for the organisation to undertake a full birthrate plus review which is being presented to board July 2019"

"High importance placed on midwifery work/life balance, childcare, set shifts and historic working patterns"

"Staff not feeling competent across the whole maternity pathway"

"High number of part time midwives"

"No concerns predicted, however intrapartum continuity will be a challenge to implement"

 "Without any additional resource to backfill the Midwives joining the CofC teams the release of staff has been the biggest challenge, not just for getting the CofC teams started but also the impact on the remaining clinical areas"

"No real issues - staff interest increasing"


The RCM response to the HoM questionnaire and other member engagement feedback

The Royal College of Midwives, as the leading professional organisation for midwives in the UK, has a key role in promoting high quality, safe maternity care. The current evidence indicates that MCOC can significantly contribute to improving the safety and quality of maternity care. The RCM therefore supports the overall recommendations in current policy documents to implement MCOC as a central model of maternity care.

In order for the implementation of MCOC to be safe and sustainable, the RCM has set out seven key conditions that need to be in place:

1. Ring fenced investment in implementation of MCOC
2. Safe levels of midwifery and wider maternity team staffing
3. Flexibility and self management for MCOC midwives and teams
4. Respect for employment and working time regulations
5. Enablement and co-production
6. Team working and mutual respect
7. Evaluation (RCM, 2018)

Part of the role of the RCM is to listen to its members to understand what the successes and challenges are in implementing maternity policy. We do this in many ways both locally, regionally and nationally, from attendance at local branch meetings or drop in sessions, to sitting on local, regional and national implementation boards. The RCM workplace representatives and regional and national officers are also contacted directly for one to one advice, support and, on occasion, representation.

The HoM survey results also contribute to our understanding of the current state of play across the UK in implementing this highly significant change.

From listening and contributing to discussions the length and breadth of the countries, we have come to understand a number of key elements.

1. Getting the foundations right
Firstly, the seven conditions, set out above and in our position statement on MCOC, published in November 2018, are all absolutely central to any implementation process. Where we are seeing implementation moving more slowly, it is clear that the absence of these conditions is a key factor, particularly in relation to ensuring safe staffing levels, and engaging with midwives and MSWs around implementing new ways of working.

2. Green Shoots
There are a significant number of midwives across Scotland and England who are now working in continuity models. Many of these midwives report very high levels of job satisfaction and enthusiasm for the new way of working. Many of the teams are reporting improved outcomes for women and their families with the new model of care when compared to the traditional model of care.

Those reporting success have identified the enabling factors as being caseload sizes, rotas and work-life balance with flexibility, self management and respect for employment and working time regulations. It is important that service leads seek out opportunities to hear from areas where things are working well and how positive change has been achieved.

3. The Change process
The implementation of this very significant service change is not always an easy process. We have repeatedly heard stories from members that the topic of continuity of carer dominates every coffee room conversation. Midwives at all levels, from top level management, to newly qualified midwives, are experiencing uncertainty and a sense of pressure to deliver change according to particular timescales and targets.

There is a proportion of midwives who do not wish to work in a continuity model. All of those charged with implementing the policy must acknowledge the different views of staff and work with all members of the maternity team to find solutions and to offer a number of different ways of working in a service. Ambitions, in terms of proportions and timescales of change, need to be realistic and take into account learning from early adopter areas. In addition, we have seen that those services who have dedicated time and resources to implementing change have seen some of the greatest successes.

4. The building blocks to the whole pathway
Service leads should be supported and enabled to explore the best possible local solutions to increasing levels of continuity. In some areas, in the first instance, this may be focussing on improving levels of antenatal and postnatal continuity and the proportion of women who receive one to one continuous care from a midwife in active labour, before moving on to increase continuity of carer across the whole pathway.

In some remote and rural areas, this may be acknowledging that increasing continuity across the whole pathway will be best achieved by focussing on increasing the number of local births in midwife led settings including homebirths and freestanding midwife led unit births. While midwives working in remote and rural areas may be able to increase the proportion of women from their area that they are able to care for during labour and birth in more distant obstetric led units, it may not always be achievable to reach the same proportion of women as in more urban areas.

Finally, a word about evaluation, the seventh of our conditions. To really ensure that we make these important changes in a safe and sustainable way, everyone involved, from national to local implementers, must carefully plan detailed evaluation at every stage to identify the impact on clinical outcomes, maternal satisfaction and staff experience. This will allow them to shape their plans for ongoing change in accordance with the learning gained so that they continue to meet the needs of both the women and families and the midwives caring for them.