ARM National Winter Meeting 2022: Continuity of Carer is the Future. An AIMS Perspective.

Jo Dagustun, AIMS Volunteer and Campaigns Team Member

Thank you to each and every one of you for investing your precious time to be here today. I’m delighted that the ARM is encouraging a renewed focus on this hugely important issue now by way of our gathering today and I'm pleased to attend to listen and share an AIMS perspective. I bring the warmest greetings from AIMS to you all today.

I’ve also got the date for next year’s ARM London conference now firmly in my diary. It’s so important to gather, share intelligence, reflect and plan next moves.

Before I get going with what I want to say on behalf of AIMS, I'd like to briefly mention the Charities and Service Users Maternity Continuity of Carer Network that has come together this year.

The network exists thanks to the longstanding service user advocate Mary Newburn, who stepped up to facilitate the Network at the end of 2021. Thanks also to ARM stalwart Lesley Page, who has acted as a valued advisor to the Network.

Made up of a range of organisations and individuals who are all supporting the implementation of CofCer. Network members all focus on different areas of maternity service improvement - we have different core interests. But we’ve come together with a pledge to work actively to support the implementation of continuity of carer, and together we seek to keep this policy firmly on the political agenda. We don't have a budget as a Network, but already we've inspired people to get involved in the campaign, held productive discussions with key stakeholders, and stepped up efforts to communicate our support for a relational model of care. Mary and I delivered a presentation on behalf of the Network at a conference in September and we have an article about the Network’s activities in production for The Practising Midwife.

I think it's been really helpful that we have a whole range of service users and charities coming together on this key issue. I don’t think we’ve really seen this level of collaboration since before Better Births was published in 2016. And between 2016 and the end of 2021, before the Network was formed, it was sometimes difficult to detect any national lay champions of Continuity of Carer. But I think all Network members are now speaking up more confidently than ever on this hugely important issue. And just this week we reviewed together our first year’s achievements and we have agreed to keep working together in 2023.

It’s also interesting to note that politically, the Network includes some big hitters - SANDS, Tommy’s - we bridge the gap between many different lay community interests. We’re pleased that the Network has most recently been asked to contribute to the manifesto for maternity and neonatal service that the First 1001 Days coalition is preparing. We will do so gladly and we would also expect to be able to influence the Pregnancy and Babies Charity Network manifesto. Like the ARM, AIMS is a small organisation, but we need to think of all the ways we can to leverage our resources and influence others to speak up for our demands.

Continuity of Carer is a way of organising care that, if done well, facilitates safety, facilitates listening to women and facilitates organisational learning. It is - in England - a key systems ambition.

But today I want to take the opportunity to reflect on what's been happening in England since the policy direction was set - or reset - in Better Births 2016, and offer some thoughts about 'where next'.

1. As many here will know, AIMS - like the ARM - is a longstanding supporter of relational care as a fundamental building block of safe, personalised and equitable maternity service. Everyone will have their own very personal stance on this issue; some of us will remember well our own eureka moment, when the case for continuity of carer fell into place - I was lucky enough to have the chance to write about my own eureka moment for MIDIRS - I’d encourage you all to write yours down too! - and we might all have our own favourite examples of where this model of care has operated most effectively. For me, the Albany model stands out as particularly inspiring:
   • Mixed risk geographical caseload in an area of social deprivation.

   • Midwives who were committed to each other as a team.

   • A model that sought to be with woman rather than with institution.

   • That understood the power of community rather than ignoring it.

   Continuity of Carer is a way of organising care that, if done well, facilitates safety, facilitates listening to women and facilitates organisational learning. It is - in England - a key systems ambition.

   But today I want to take the opportunity to reflect on what's been happening in England since the policy direction was set - or reset - in Better Births 2016, and offer some thoughts about 'where next'.

2. AIMS has been carefully watching implementation efforts at a national level since Better Births 2016, and putting in our two penn'orth in along the way. We have also been actively observing what’s been happening in local areas, for example through our active membership of the Practical Continuity facebook page, an excellent initiative set up by Rachel Wild, and through our regular attendance and participation at a series of weekly online discussion sessions kindly and patiently facilitated by Caroline Flint. We are also members of NHS England’s Maternity Transformation Programme’s Stakeholder Council.

3. Throughout this period, when it came to continuity of carer and its implementation, it seems clear that NHS England have wanted to be hands off and respect the role of local areas to design their own local implementation strategy. This is understandable in a system where power is diffuse and where NHS England has only limited leverage. This links to important questions about how much influence and what kind of influence NHS England has, in regions, in LMNSs (now ICS areas) and in NHS Trusts. And, in that context, questions about how exactly NHS England can fulfill its stated mission: “We lead the NHS in England to deliver high quality services for all.”

4. But this ‘hands off’ leadership has been hard to watch. Very early on, there were signs that local areas weren't bought into this key element of the Better Births vision. I saw this as I noted that junior staff were being expected to lead on the policy implementation without having any real power to effect such a massive change. That workarounds to hit targets, rather than achieve genuine transformation, were being created. So the laissez faire strategy was problematic. Something more sophisticated was needed.

   And indeed more direction from centre did then start to emerge: a clinical lead for the programme was established; levers such as the NHS annual contract and the NHS Long Term Plan were brought into play; and eventually, Continuity of Carer became increasingly understood as key part of the influential safety strand of the Maternity Transformation Programme, rather than as part of the rather marginalised, ‘nice to have but not essential’ ‘personalisation and choice’ strand where it had first sat.

   This activity meant that the system started to get the message that NHS England was serious. That this policy wasn't going anywhere. And this is when we started to hear increasing levels of complaint about the top down nature of the approach.

5. But this central direction, I would argue, was always fairly light touch, at least from where I sat in AIMS. Deadlines were continually pushed back, and the targets were often more around demonstrating planning for CofCer rather than actually achieving it, for example as part of NHS Resolution's Maternity Incentive Scheme.

   And the ongoing lack of transparency around progress, around plans, around the reasons why implementation was slow, was quite remarkable, with clear information extremely hard to secure, from the local to national level

6. That said, lots of effort, we know, was being expended on the ground, across England, with varying levels of effectiveness. A few Trusts made some real progress. But the workarounds we started to see in other areas were simply stunning in their misconstruction of the aims of the policy, in the attempts to hit targets rather than implement the policy as intended. Some would say that this was a matter of policy not being communicated clearly enough. The targets being unclear. My reflection is that people who wanted to listen heard. Or perhaps its better to say ‘people who didn’t want listen didn’t hear’. But let’s remind ourselves again of what sorts of things we saw on the ground:

   • Midwives on so-called continuity teams were working shifts in fixed locations, which made it unlikely that any real continuity with 'their own women' would be achieved.

   • Sham teams made up of community and labour ward midwives were created, which again allowed Trusts to declare they were meeting targets but with no intention that a named midwife would walk with us through our entire maternity journey.

   • Non-geographical teams were set up, teams that were never going to be efficient enough to work, based on midwives' journey times alone.

   • There was a focus in some areas of the country on 'easy' areas for implementation (the better off areas), rather than a determination to deliver relational care in the areas where women who were most likely to see significantly better outcomes actually lived.

   • Midwives on continuity teams were repeatedly asked to pick up other work due to short staffing (or should that be poor staff management?), which destroyed their ability to support their own caseload.

   • So many schemes were put in place and then abandoned when found to be unworkable.

   To all midwives who have suffered the personal fallout of poor implementation, I’d just like to say sorry. When AIMS calls for a fundamental shift to relational care, we do not call for it to be implemented at the cost of staff wellbeing. Quite the contrary. And we expect the ongoing evaluation of implementation to date to speak to this important point. More on that later.

7. The centre perhaps did all it could do in such circumstances: it responded by seeking to offer more support, more help, more guidance to Trusts. To correct misunderstandings, it reiterated that the important team element of the policy should not be mistaken as a shift of focus away from what a coalition of campaigners in the run-up to Better Births - a coalition including AIMS and the ARM - had called 'a midwife for me and my baby'.

8. But the implementation programme was ever vulnerable. There were vested interests - and I'm afraid that included some midwifery leaders - who had never bought into the benefits of relational care; who seemed to be unable to understand why full pathway relational care matters to women, to safety, to quality improvement. Especially when the switch to working in a new way just seemed too hard.

9. The programme was then badly shaken by the Shrewsbury and Telford Report's recommendations, even though these went far beyond scope and were not in themselves evidence based. Indeed in that - Ockenden - Report there was very little mention of continuity of carer, and its absence seemed rather curious when many of the vignettes suggested that relational midwifery care could have gone some way to avoiding harm.

10. Add in the lasting effects of the pandemic and Brexit, and the pressures on staff, linked to poor culture in many Trusts and staff and other resource shortages, and the destabilisation of the policy was perhaps inevitable. As you will know, the national targets for universal rollout are now paused.

11. But the policy intent remains in place. The policy ambition in England, just as a reminder, is this:

    For midwifery continuity of carer to be the default model of care for maternity services and available to all pregnant women in England, with rollout prioritised for those most likely to experience poorer outcomes.

    • In the short-term, we can continue to expect a focus on the health inequalities driven Core20PLUS5 agenda and delivered via enhanced midwifery continuity of carer teams and there is some extra cash available for this.

    • There is a key focus on evaluating the implementation to date - and to learn lessons. Chris McCourt at City, University of London is leading up this evaluation work. Get in touch with her!

    • Work continues too on building the research base further, for example looking in detail at the potential benefits of relational care on those with particular pre-existing health conditions.

    • Continuity of Carer implementation training resources are being developed, with an NHS England tender currently out.

    • And the national team remain in place to support Trusts in their implementation efforts.

    There is also a clear goal at national level to reduce unfilled maternity posts:

    • Our ambition for 22/23 aims to reduce maternity vacancy positions to as close to zero as operationally possible.

12. So that’s what’s on the table. But I think it’s also important to look back to 2016 and what has been happening since then. It's perhaps easy to spot the problematic elements of the implementation programme to date, and I recommend we do so in a spirit of moving forwards:

    • Where was the shared vision? Has there been enough effort to create a shared vision? What more could usefully be done?

    • How well has the evidence base been communicated? What would help more people understand the evidence and respond to doubts?

    • Do Trust CEOs understand why this transformation of maternity services can help them avoid future scandals and help them deliver a safe, personalised and equitable maternity service? What might bring more of them on board as supporters?

    • How secure are the conditions for change? Are all Trusts ready to transform, or does a lack of change management skills in many areas, a lack of trust between staff and management, and in some cases simply a lack of staff, inevitably hamper progress? How can we build a transformed maternity service when the system itself does not seem to have the capability to transform? How can the basic building blocks necessary to move forwards be secured via the forthcoming NHS England Single Delivery Plan for maternity services?

    • And it's simply bizarre, as an outsider, to now reflect on what little support this programme seems to have had from the teams at NHS England who are supposed to be experts in how to lead large-scale change, or from the MatNeoSip and QI teams across the country. I’d ask “where have they been when we needed them”, but - more positively - a better question now is perhaps: what can we do to convince these teams that a structural shift towards relational care is their business?

13. Alongside all this, we have a particular problem in the UK - including amongst service users I'm sad to say - in even conceptualising midwives as key to a safe maternity system, or as trustworthy. We need to put this into context. How far, in some people’s minds, is a call for Continuity of Carer, for example, from the oft quoted ‘normal birth at any cost’ ideology? It can sometimes feel that some people think we are proposing a dangerous new model of care, a radical change to what we have that somehow strips out every other positive element of the maternity services.

    But for me, that’s not what relational care is all about.

    Rather, it’s about whole systems change,

    • change that is the business of the entire maternity team,

    • that would see midwives better assured that they have the whole team alongside them, ready to support when needed;

    • that would see linked obstetricians working closely with midwives in continuity of care teams;

    • that would see improved relationships being built both within and between various groups of maternity healthcare professionals;

    • that would support safety in a way that multiple ad-hoc downstream initiatives - rescue initiatives - consistently fail to do.

    And integral to all that, relational care as the bedrock of the maternity service seems to offer the potential for a more humanised - and human-rights respecting - maternity service, for service users and staff alike. By placing a value on the therapeutic value of relationship, by working through relationship, we build a way of working that values healthy relationships, both with service users and between staff. It values listening, understanding and acting on what we hear.

    We don’t need any more reports to tell us how broken our maternity system is. We need instead some long-overdue change that is indeed radical in its ambition, but not radical in the sense of being unsafe, dangerous or foolhardy.

    If implemented well, a shift towards a relational model of care should go a long way to very practically create a work environment that leaves behind toxic cultures. The toxic cultures that will always arise in a broken maternity system. Radical reform is needed.

14. This conference has a future-focused theme, so I want to offer some thoughts on that before I conclude:

    • First, Let's not give up on the promise of relational care for all, as a universal offer within the NHS. It's vital that we keep this policy alive. For all of us, and those who come after us. The policy ambition is in place in England: we need to do all we can to keep it in place.

    • Second, Let's celebrate the fact that a diverse group of charities and service users have come together in 2022 to support the implementation of Continuity of Carer. Maybe that should have been done earlier, but we are now here and not going anywhere.

    • Third, Let's all try to support the current CORE20PLUS5 focus, and see whether we can use the successes from that implementation phase to win hearts and minds as we then turn to universal implementation

    • Fourth, Let’s all be on the look out for - and challenge - policies and practices that will make relational care harder to implement in the future, and support those which will make it easier; and

    • Finally, Let's all use our influence, especially at local - ICS and Trust level - to keep this policy ambition alive. Because in the absence of national targets, there is still so much that local communities, ICSs and Trust CEOs/Boards can do to achieve transformational change in their local areas. But to do this we need to persuade more people that relational care will go a long way to helping us deliver safe, personalised and equitable maternity care. And that’s where communication comes in. We can all help on this one. Let's keep talking about the rationale and benefits of this model of care. Let’s talk in a grounded a way as possible, to different audiences, about how relational care works. You might be able to pick specific cases and write them up (anonymously and with consent). Think about blogging, offer to speak to your local community groups, to your MVP, to your local radio. Offer to answer questions. If there’s anyone here who would be willing to assist the Charities and Service Users Network with any comms we do, please let me have your name and contact details. Send us stories, so that the Network can use them in future articles. Contact your regional lead midwife and ask if you can collaborate on an MCoC training event for your region.

    • In summary, let’s keep talking about this. Relational care for all, as the bedrock of a high quality maternity service, is a realistic ambition.

I’d like to conclude by flagging up a key opportunity we have over the next few months. Just this week, the Board of NHS England took an item on East Kent. In the context of that hard-hitting report, the Board was clear that this issue ‘had to be sorted out’. In the context of decades of reports exposing similar issues of dysfunctionality in maternity services, Bill Kirkup was clear that we needed a different - systems wide - approach.

So the Board have asked NHS staff to bring them a refreshed maternity Single Delivery Plan in the Spring - including financials - that is challenging, direct and clear. That sorts this issue out. The Board want this sorted and so do we. I suspect that there are many in this room who might usefully share their thoughts on just how to radically improve the maternity services. And in doing so, to repeat the words of that NHS England Board member, let us be challenging, let us be direct and let us be clear.

Thank you for listening to this AIMS perspective.

Thank you to the ARM for inviting me to speak.

Thank you to Mary Newburn both for working alongside me over the summer as we reflected on CofCer implementation to date and for offering comments on what I planned to say today - I also bring her apologies - she is sorry she couldn’t be with us here today.

Thank you to everyone who works so hard to maintain the ARM's valuable voice on this issue.

Thank you to each and every midwife who either does - or who yearns to - provide the relational care you know - we know - is so valuable.

I look forward to the rest of what promises to be an inspiring meeting. Thank you.

Speech given at ARM Winter Conference, 3rd December 2022

Editors note: You may also be interested in the article by Jo Dagustun and Mary Newburn in Practicing Midwife
A Midwife of My Own: Public Support for Implementation of Midwifery Continuity of Carer