Providing continuity of carer is perhaps one of the most challenging principles of maternity transformation. Juliette Astrup looks at how some of the early adopters are putting it into practice.
This is how Sarah-Jane Marsh, chair of the Maternity Transformation Programme (MTP), NHS England, described continuity of carer at a recent seminar.
While there is a broad consensus that it improves both women’s experience and their outcomes (RCM, 2017) – women who have had continuity of carer are 16% less likely to lose their baby and 24% less likely to have a preterm birth – the move towards it has also raised legitimate concerns among midwives about how this different way of working might impact their work-life balance.
But, with a target set that, by March next year 20% of women should be booked onto a continuity pathway (NHS England and NHS Improvement, 2018), now is the time to ‘get stuck in to continuity of carer,’ as Sarah-Jane puts it.
And the Better births early adopter sites have been doing just that, piloting new continuity of care models in a myriad of different ways.
Three models – 17 ways
The North West London Local Maternity System (LMS) has designed three different models to deliver continuity and is piloting them in 17 different iterations across the services.
As well as a team caseloading model, with teams of four to six midwives working within a buddy system to offer continuity throughout the pathway, there is a new birth centre continuity model, which sees teams working in midwifery units (MUs) gradually taking on caseloads, providing a named midwife for antenatal and postnatal care, and a team approach to birth.
In addition, hospitals across the system are working towards a team continuity model, a more traditional group practice model, which aims to offer improved continuity across antenatal and postnatal care by reconfiguring teams, rescheduling clinics and careful management.
The aim was to design models which were ‘sustainable, suited the workforce, and suited the women’, explains NHS England’s MTP early adopters implementation manager Victoria Lyon.
‘It led to the design of three different models which we wanted to test across sites. They are all in a different position in terms of workforce, the demographic of the women, their financial status, so we wanted to be flexible,’ she adds.
Between them the pilots are offering continuity to a whole range of women. Caseloading teams are working with women with complex social needs, with multiple pregnancies, and with medical complexities, such as diabetes. And a birth centre continuity model for mixed-risk women has been operating at Hillingdon since October, and launched at Northwick Park in April.
Building a foundation
The aim is to get the percentage of women booked into a continuity of care pathway up from the 2016-17 baseline of 1%, to 20% of women by 2019 – the majority through the team caseloading model.
While this model doesn’t provide for continuity of carer at birth, it represents a solid foundation for that ambition moving forward, explains Anita Hutchins, LMS chair and lead on the postnatal workstream.
‘Based on the current set-up of NHS funding, which is being looked at by other workstreams, we know we cannot provide a thorough continuity of carer model for every single woman, but we can at least improve two parts of the pathway, and focus on having a named midwife as a single contact point.’
Victoria adds: ‘We are building a foundation from which we can move on to the next phase, which is much simpler to implement if you have the staff on board with you.’
She says they have ‘been on a journey’ in terms of continuity; midwives had been concerned about how their jobs might change, but as new models of working came in, it has had a ‘snowball effect’, which is ‘helping midwives understand what it means, and getting everyone on board,’ she adds.
And while challenges remain, including managing those midwives who work flexibly, some of whom live outside of London, and providing postnatal care across multiple provider and commissioner boundaries, there is a clear sense of momentum, adds Anita.
‘It’s definitely a better way of working for women and families, and also for teams. I don’t think anyone thinks things will go backwards from here – it’s all moving forward quite quickly.
‘We’ve gone from thinking “how are we going to do this?”, to thinking “what do we do next? Let’s crack on with the next piece of work”. It’s really exciting to see midwives and obstetricians really getting engaged.’
Pop-up birthing centre
Cheshire and Merseyside is another early adopter site now seeing its plans come to life. Their innovative ‘pop-up’ birthing centre, launched at the Wirral’s Seacombe Children’s Centre on 20 March.
Catherine McClennan, programme director at the ‘Improving Me’, the Cheshire and Merseyside Women’s and Children’s Services Vanguard, says the aim is to address the lack of choice for women in the area by providing access to a freestanding MU for the first time.
It has facilities for one woman to give birth and is staffed by six midwives, working in a team continuity of care model, who are also responsible for the home birth service. Women on low-risk pathways will be able to have all their appointments there, from booking through to postnatal care, as well as the birth, seeing their named midwife, or a member of the small team throughout.
The unit, the first of its kind in the country, will be in place for at least the next year, when it will be evaluated to test out how well it is received and used and how sustainable it is within the system. ‘It’s almost like a feasibility study,’ explains Catherine.
It also satisfies Better births’ recommendation for a community hub model, embedding midwives in the community alongside a raft of other wrap-around services, including health visitors, a paediatric clinic, and support and education classes for families.
‘It’s a move towards integrated care with local services and social services,’ adds Catherine. ‘It’s a great test of so many things which go beyond Better births, to the Five Year Forward View, the STPs – it’s the future of care.’
And the arrival of the pop-up freestanding MU has triggered a surge in interest in home births, she adds.
Since the continuity team was established in January this year they have had seven home births, and another 36 women have expressed an interest in either home birth or the birth centre up until October – compared to a total of 29 home births across the Wirral last year.
‘What it has done is really opened up conversations with women about choice,’ says Catherine. ‘They feel there is now choice on offer. And the fact that home birth rates have gone up so dramatically is also really positive because it reflects what women want, and that we are responding to that need.
‘Hopefully this pop-up will stay up!’
NHS England’s MTP early adopters lead Sandra Smith says across the board the early adopters are ‘making great progress’ and are on target to deliver on their objectives by December this year when the project comes to an end, or ‘to share the good reasons why something hasn’t worked in their local area – which is just as important’, she adds.
‘The whole point of this project is testing out different methods and approaches in a safe space, and to share the learning across the LMSs and across England, to point them in the right direction, or steer them away from what hasn’t worked,’ she adds.
‘They are very thorough in what they do – they realise there won’t be another chance, certainly not in our lifetime, to transform maternity services in the way we are doing now.’
And momentum is definitely gathering in this final year, adds Sandra: ‘I think last year it was a lot about planning and processes, about what data to collect – a lot of preparation. Now things are really happening, and the drive and the energy to get there is increasing.
‘Last year the curve was a gradual one, but we are on the steep implementation part of the curve now, which is very exciting.'
NHS England and NHS Improvement. (2018) Refreshing NHS Plans for 2018/19 See: ntw.nhs.uk/content/uploads/2018/02/Item-9i-Planning-Guidance-18-19b.pdf (accessed April 5 2018)
RCM. (2017) Brief scoping of the continuity of care evidence base. See: rcm.org.uk/sites/default/files/Brief%20scoping%20of%20the%20continuity%20of%20care%20evidence%20base.pdf (accessed April 5 2018)