Two years after Better births set out its vision for safer, more personalised, family-friendly care, Juliette Astrup takes a look at the progress being made on improving safety.
Safety is the ‘golden thread’ running through the Maternity Transformation Programme in England. It is underpinned by the national maternity ambition to halve the rate of stillbirths, neonatal and maternal deaths, and reduce preterm births from 8% to 6% by 2025 (Department of Health, 2017).
And, while progress is being made across the nine national workstreams supporting the implementation of Better births in England, work to promote good practice for safer care in particular is having a tangible impact.
Central to this is the Maternal and Neonatal Health Safety Collaborative (MNHSC), a three-year national programme that trains nominated improvement leads and supports local teams in developing and implementing quality improvement projects. In Scotland, the equivalent is the Maternity and Children Quality Improvement Collaborative.
A year on from MNHSC’s launch, the 45 trusts that made up the first wave are now sharing their learning ahead of the second wave in March 2018.
Initiatives so far have targeted a range of areas, including reducing sepsis, improving outcomes after perineal damage in childbirth and smoking cessation.
Mandy Forrester, RCM head of quality and standards, says: ‘What has been really impressive is the way teams have engaged with the work, supported at a national level, to produce really practical improvements. What we must now do is harness the learning from all these initiatives and put processes in place to make it safer for women and babies.’
Among the success stories is Queen Alexandra Hospital, part of Portsmouth Hospitals NHS Trust, which has halved stillbirth rates in three years.
Alison Scannell, the hospital’s maternity assessment unit (MAU) coordinator, says that following the launch of their 24-hour maternity assessment unit in 2015, the unit took a closer look at demand for scans and found women were waiting up to 15 days for both reduced fetal movement scans and growth assessment scans.
By creating dedicated scanning slots each day, two for reduced fetal movement and four for growth scans, waiting times were brought down to between 0 and 72 hours.
These steps were combined with the introduction of a midwife sonographer and a midwife lead in the MAU to take a ‘helicopter view’, says Alison. ‘We effectively “triage” all the scanning requests. We now have an enhanced view, so we are able to manage clinics and put resources in place as and when we need to across the department.’
Another step forward has been sonographers training midwives in third-trimester scans – upping capacity, but also bringing about a new level of collaboration between midwives and sonographers, enabling them to understand, explains Alison, ‘what information is relevant to midwives, the implications for the women, and what the next steps might be’.
The improvements are having a dramatic impact. In 2015, there were 4.77 stillbirths per 1000 compared with 3.54 per 1000 in 2016. And while the 2017 figures are yet to be confirmed, the rate is currently projected at 2.24 per 1000 births.
The work of the MAU saw it highly commended in the final of the Innovators Cup for Fab Change week, and winner in the Best Improvement category of Queen Alexandra’s Best People Awards, something they are rightly proud of, adds Alison.
The Southampton, Hampshire, Isle of Wight, Portsmouth (SHIP) maternity academy is a ‘virtual academy’ that brings staff from all four services together for training in a bid to improve consistency and reduce variation across the local maternity system. It was set up with money from the Maternity Safety Training Fund.
Consultant midwife Clara Haken, the senior clinical fellow leading the SHIP academy, says work has included the development of a high-dependency care training programme, and joint PROMPT – PRactical Obstetric MultiProfessional Training – across all four services, helping to bring down barriers, as well as offering a host of practical benefits.
‘It makes training more flexible and accessible: if you are only taking 10 people out of the workforce from each service instead of 40 out of one, it makes it more achievable,’ Clara says.
‘Sharing innovation is really helpful. People coming from different services with different experiences certainly come up with new ideas.
‘It is also a great way to improve knowledge of other local services. Women move across boundaries, and with better understanding and more commonality of training we can support those women better and give better care.’
Katie De Freitas, one of three improvement managers supporting work across the collaborative, says improvement leads were given a lot of support to develop their quality improvement expertise, helping them to evaluate processes, and implement and measure change.
‘You have maternity teams with a lot of fantastic ideas, but what this programme is supporting is the “how” – how do you make that happen?’ she says.
And while the learning is being shared with wave two and wave three trusts, it is not simply a case of replicating it.
‘There is a massive spread of learning across the collaborative,’ says Katie. ‘My caveat would be that it’s not just about understanding what needs to be done – it is how they’ve done it, the processes and how they will achieve it that will look very different in each individual unit.’
Transformation in Scotland
In Scotland, work continues to bring the ambitions of the Best start review into view and implement its 76 recommendations by 2022.
The national board has now met four times since August 2017, and the three working groups – continuity of carer and local delivery of care, perinatal services, and workforce and education – are now starting to meet.
Implementation groups have now been set up within the five Early Adopter sites announced in October, and the other nine health boards have been charged with bringing forward 23 of the Best start recommendations identified as being deliverable and led at a local level.
Some are already looking at how continuity-of-carer teams can be established. For example, Angus in Tayside, which isn’t an Early Adopter site, is providing greater continuity with teams of seven midwives; Argyll in the southern Highlands, a rural area with small teams, is focusing on women seeing the same midwife throughout their care, explains Mary Ross-Davie, RCM director, Scotland.
And the RCM Scotland team has run a series of well-attended events focused on continuity of carer, which a predicted one in 10 midwives in Scotland will see by the end of the series.
Midwives are asked at the start and end of these sessions if they would like to work in a continuity model or not, says Mary.
‘It varies, but in the most negative areas where you begin the day at 50/50, by the end of the day 80% are for continuity working and 20% against.
‘Just understanding what it means and hearing the positive experiences of midwives who have worked in that way can help midwives think this is something they could do.’
She adds: ‘It is really exciting what is happening in Scotland. Lots of people are anxious, but there is also a lot of positivity and some real progress being made.
‘We are lobbying hard to ensure that there is adequate funding to really support the change – that is a key focus for us at this stage, to ensure that midwives are given enough time, education and support to make the significant changes to the way they work.
‘We would encourage midwives everywhere to get involved in local sessions and implementation groups, so that they can really help shape and inform the change.’