The elephant in the room

By Mary Ross-Davie and Lia Brigante on 07 March 2018 Midwifery Continuity of Carer - MCOC

Mary Ross-Davie and Lia Brigante show how the RCM supports members on continuity of carer.

Both England and Scotland’s current maternity strategies – Better births (2016) and Best start (2017) – place continuity of carer as the central model of maternity care.

We know from our engagement with members across the UK that the prospect of implementing continuity of carer elicits mixed reactions.

Many midwives welcome the introduction of a model of care based on strong research evidence that demonstrates a range of positive outcomes for women and babies, as shown by the efficient evidence reviews undertaken as part of the Scottish maternity and neonatal review (Scottish Government, 2017) or the Cochrane review on midwife-led continuity models (Sandall et al, 2016).

However, many of you are also concerned about a number of issues:

On call

Will I need to be on call 24/7 and then burn out? How can I have a work-life balance in a continuity model?

Are there enough midwives to implement this?

We estimate in England that we have a shortage of around 3500 midwives who could provide a high-quality service, and we continue to argue for this to be addressed. RCM guidance, based on Birthrate Plus, is that there should be one midwife for every 29 women at any one time. Evidence from trials suggests that continuity models of care don’t require more midwives than a traditional model of care. In Scotland, we currently have enough midwives to meet the suggested RCM/Birthrate Plus ratio of one midwife to 29 women and the Scottish Government’s suggested ratio of one midwife with a caseload of 35 women at any one time. It is important to recognise that caseloads will need to be smaller when caring for women in rural areas and for women with complex vulnerabilities.

We tried this before and it didn’t work – it’s just too difficult to upscale and maintain

A number of schemes in different parts of the UK introduced continuity and caseload models of care following the Changing childbirth report (Department of Health, 1993). Many of us remember those models – some with very happy memories of a fulfilling time in our careers, some with memories of difficulties between different parts of the service and the demise of many caseload schemes.

The RCM is seeking to address these concerns. At national level, we are arguing strongly for adequate investment by the Westminster and Scottish governments in implementation and transition arrangements, for sufficient staffing and high-level leadership, and for support upscaling into sustainable models. At a local level, we are aiming for RCM regional and national officers to be included in all local implementation groups and discussions to ensure that our members’ voices are represented.

The flipside is for us to support our membership in developing knowledge and skills about how continuity models can be successfully implemented in a way that works for staff as well as for the women they care for, as we believe that the prize is worth the effort. We are doing this in a number of ways:

We are developing a range of resources that can be used individually or in small groups: there will be a new module on the RCM’s learning platform, i-learn, in April, and a new interactive workbook, Can continuity work for us?, has just been published for RCM members (see below).

We are running ‘train the trainer’ sessions with all RCM regional and national officers and organisers so that they can run local sessions on request at local branch meetings or learning sessions. If you would like to organise a local session that looks at the evidence for continuity, the realities of working in a continuity model and help for midwives to understand the anticipated caseload and workload, please get in touch with your local RCM learning rep or steward.

In Scotland, we have run a series of five regional events working through some of the key questions about implementing continuity. More than 200 midwives attended and evaluated them very positively. Many have told us that these have allayed a great deal of their fears and busted some of the myths about continuity. We are using the template of the Scottish sessions to shape sessions to be offered across England.

So if you are feeling worried – and/or excited – about continuity of carer, address those elephants.

Read as much on this subject as you can, use the valuable resources that the RCM, the Scottish Government, NHS England and others are producing and get involved in local sessions and discussions about how continuity of carer could work for us.

Can continuity work for us?

This new resource has been developed by the RCM following three years of conversations and expert input on how to scale up midwife continuity-of-carer (MCoC) models. Organisations that had set up one or more teams were consulted by the RCM in order to unpick the elements that make the model sustainable at individual (midwife) and organisational (NHS trust or health board) levels. Different formats were used to bring experts together and gather important data, including consultation exercises, workshops, interviews and webinars. A range of stakeholders (more than 200 participants) were included: midwives happily working in the model, midwives that had left the model, midwifery managers and academics.

Some organisations have successfully set up one or more MCoC teams and a few are maintaining more than five. The support available to on-call midwives triples when multiple teams are operating within the same organisation – for example, second-midwife night cover – which increases sustainability. This and many other lessons that emerged from the stakeholder sessions have been included in the published RCM resource alongside some of the evidence on MCoC.

The resource includes practical information, definitions of key elements of MCoC models and logistics tips. Practical exercises throughout the resource enable you to work through some of the key issues individually or in small groups. Hopefully, they will contribute in sparking local conversations and ideas for scaling up or setting up MCoC teams as well as individual reflections.

Midwives from urban, rural and remote areas across the UK informed the research, making it valuable to all RCM members wherever they work.

RCM members can access this resource in our Publications section

Mary Ross-Davie is RCM director for Scotland and Lia Brigante is RCM quality and standards advisor