MTP: Transformation fever
By Amanda Rogers, Fiona Ghalustians on 03 September 2018 Midwives Magazine
Amanda Rogers and Fiona Ghalustians describe their experiences of going ‘further, faster’ at an Early Adopter site in London, implementing Better births as part of the Maternity Transformation Programme.
The North West London Collaboration of Clinical Comissioning Groups (CCGs) covers eight boroughs across inner and outer London – a large, diverse and densely populated area. Maternity services are provided by six maternity units across four NHS trusts:
- Chelsea and Westminster Hospital
- Hillingdon Hospitals
- Imperial College Healthcare
- London North West University Healthcare.
Around 30,000 babies are born here each year, with an ever-increasing prevalence of socially and medically complex women requiring care during pregnancy, birth and beyond.
Creating new ways of working
Following the successful reconfiguration of our maternity services in 2015, which saw the emergence of true multidisciplinary partnership and collaboration, we applied to become one of seven Early Adopter sites across England to implement recommendations from Better births by testing and evaluating new ways of working in maternity care, and launched the project in January 2017.
We began by mapping the current care pathways for women in three categories: low-risk and uncomplicated care, shared obstetric care and socially complex care. We identified teams in the local area that were already providing exemplary continuity and postnatal care, while also highlighting areas on which to focus our mission for improvement. These included improved consistency of information and testing new ways of working with women who require both low- and high-risk care.
Our next step was to learn what our staff and service users wanted, gauging how those on ‘the front line’ felt about providing continuity of care through new ways of working. We were particularly interested in learning about any perceived barriers to making these a reality. We engaged with women and their families, through existing Maternity Voices Partnerships and events at local children’s centres. We also introduced a purpose-built engagement website, allowing women to provide us with feedback on their experiences of care, in line with the themes highlighted in Better births.
Three potential new ways of working began to emerge. In collaboration with the project team, each trust modelled the feasibility of the options and agreed what it could test and implement within the life of the project and beyond. Our project management team worked alongside senior midwives at each maternity unit to make our shared aspirations achievable by support with modelling, reconfiguration, engagement and recruitment. Throughout this process, learning has been shared, successes and challenges explored, and momentum maintained through regular trust and sector-wide meetings.
A group of professionals from across the sector has been busy collaborating on the development of a personalised postnatal care planning tool. This helped to form a booklet that was designed to be discussed with women during antenatal appointments to prepare them for the often under-explored leap into parenthood. This tool will now be included in our soon-to-launch north-west London mum-and-baby app, which will provide women with digital antenatal, birth and postnatal care plans that can be completed to suit their individual needs and wishes.
As the project has grown, new priorities and initiatives have evolved. Your pregnancy and After your baby’s birth information booklets (pictured left) were developed by the project team, clinical experts and service users to improve the consistency of information that women and their families receive. Available in both paper and digital formats, and in different languages, we aim to ensure all women receive the same high-quality and evidence-based information, regardless of where in north-west London they choose to give birth.
Arezou Rezvani, lead midwife for community, caseload and specialist midwives at Imperial College Healthcare NHS Trust, says: ‘The team has worked in collaboration with a variety of clinicians, consultants and midwives to ensure the standard of care and the services which are provided across north-west London are the same. Feedback from staff and mums is that the After your baby’s birth booklet has been really useful and informative.’
To date, we have launched four different models of continuity of carer (see table), operating in 14 different ways across north-west London, with at least nine more starting over the autumn and winter. As clinical outcomes improve, staff satisfaction has increased and real change has begun to feel sustainable, the vision to achieve more has grown at an exponential rate.
Model 2 is an emerging and ever-growing success with women and staff alike. This model is easy to implement, operates within current staffing establishments and has the potential to indirectly contribute to cost-saving and quality improvement measures.
Our caseloading teams are thriving, and provisional data shows great promise: one team achieved a home-birth rate of 11% in its first two months. These teams have each been supported to build a rota and on-call system that works for them and is flexible around midwives’ lives – a method undoubtedly key to their success.
Madoussou Dosso, a midwife at Chelsea and Westminster Hospital who recently began working in a team that provides one-to-one maternity care, says: ‘I’ve been working in this new team for almost four months. I enjoy working this way because you get to build relationships with the women you are caring for. The real highlight for me is watching these women grow and seeing how they progress with their baby. Being on call can be tiring, but it’s also exciting to know that I am going to be there when one of my women gives birth.’
Never underestimate the amount of time it can take for the successful delivery of new ways of working. From concept to establishment, there are many hurdles to cross and both foreseeable and unpredictable challenges to overcome. Recruitment to certain models has been, and remains, a challenge, but as the fever for transformation grows, so does the curiosity of those who were initially sceptical about their ability to work in a new way.
We can’t deny that the current financial and staffing climate has been a challenge, a picture that is widely mirrored elsewhere in the NHS. Key steps to tackling this include careful planning of activity and maintaining midwife-to-women ratios within current staffing establishment levels. Unsurprisingly, the transition has the potential to carry financial burden; however, the longer-term indirect savings associated with improved clinical outcomes, experience and length of stay make a compelling case for commitment to change.
Mindful of the NHS’s charge as an Early Adopter site to ‘go further, faster’, the ambition to deliver continuity of maternity care to women will be achieved in three ways: continuation, collaboration and evaluation.
The local maternity system (LMS) intends to deliver all recommendations set out in Better births by 2020-21 and to achieve sustainable continuity of carer for a significant proportion of women choosing to have their baby in north-west London.
We have laid the groundwork to ensure that women and their families are able to receive consistent, personalised care according to their needs and delivered by midwives and doctors that they know. This will become ‘business as usual’ when the Early Adopters team concludes its work at the end of this year.
Collaborative working is enabling the LMS to deliver on a number of key projects. Maternity Voices Partnerships have been established at each trust, and are being successfully led by service users. These groups are influential in the way we look to improve care and women’s experiences of our services.
Our new maternity app is currently being user tested and will launch this autumn. This app will contain all the information women and their families need to know about having a baby in north-west London and will replicate the information already available in the booklets. The app encourages women to create personalised care plans to support each step of their journey into parenthood.
We are striving to ensure that women are aware of the three choices they have in relation to which setting they give birth in (at home, in a midwife-led birth centre or on an obstetric labour ward), in all of our maternity units. This is while promoting conversations that are led by women when meeting with their care providers during pregnancy to discuss their birthing options.
An evaluation partner supports the collation of project outputs and the formation of a toolkit to guide the national agenda to implement Better births. The new models of care are subject to key performance indicators that will help to evaluate the improvements, with a large-scale comparative audit sample to track the impact of the changes we have made. Midwives working within the new models are gathering this evidence thus learning about service improvement first hand.
The goal to have 20% of women booked onto a continuity-of-carer model by the end of March 2019 is challenging, but we are striving to achieve this by working closely with midwives and service users to design models of care that work for our diverse population. We expect that the financial investment we have made in our continuity models will result in direct and indirect financial savings and increase the positive experience of staff and the women in our care.
Amanda Rogers and Fiona Ghalustians are members of the midwifery project management team at the North West London Collaboration of CCGs