Implementing Better Births: Continuing the campaign for continuity of carer. A call to action!

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AIMS Journal, 2018, Vol 30, No1

By the AIMS Campaign Team

AIMS has long campaigned for a shift in emphasis in the maternity services to one that offers truly woman-centred care, anchored around the key midwife-woman partnership. AIMS believes that maternity care founded on that mutually respectful and trusting one-to-one relationship is crucial to achieving our shared goals of effective and safe maternity care. Forming a relationship with a primary carer creates a secure basis for care even when birth becomes complicated and demands a multi-professional approach.

Whilst AIMS is therefore delighted that the Better Births recommendations around continuity of carer form a key part of the national Maternity Transformation Programme, the AIMS Campaign Team is also clear that there is no room for complacency. Rather, there is a continuing need for local birth activists to work to ensure that this transformation is delivered across the country. The local implementation phase of this campaign is crucial. If we fail at this stage, we may have to campaign for another generation for this opportunity.

Thus AIMS is calling on local campaigners to take action to secure this promise of continuity of carer for women and families in their local areas. Each area will be different in terms of how this model can best be matched to local needs. And every area will be different too in how we best engage in this work: campaigners will need to be creative in terms of how they campaign, taking into account what’s already happening locally. In some areas, it might be most effective to work with an existing Maternity Voices Partnership, for example: maybe you could offer to sit on the partnership as the ‘continuity of carer’ champion? In other areas, it might be worth talking directly to the leaders of your local maternity system, to understand how implementation is being facilitated at that level.

Priorities for action

1. Find out what’s going on, and then get involved in the development and scrutiny of your local plans for implementing continuity of carer. Are these plans realistic? Are they sustainable?

• Are we setting up schemes that are designed to fail? We know that burn-out has been a major factor in previous attempts to implement continuity of carer schemes. So given the casemix envisaged for any given continuity team, do the numbers of women to be cared for seem realistic, or do they just seem too high? If the casemix is made up of many women whose care needs will be particularly time-consuming, for example, you will want to query how the caseload allocation has been modified to reflect this. (Usual allocations tend to be within the range of 28-40 women per midwife per year, depending on casemix, for a full caseloading continuity model.) It is also worth scrutinising carefully any plans for non-geographically based caseloading teams: do they allow for enough time for midwives to travel between appointments?
• Do local managers understand what is meant by true continuity of carer? Is there a good commitment to the notion that continuity means continuity across pregnancy, birth and postnatally? If you hear your local service already muttering about the likelihood that intrapartum continuity will not be achieved - because midwives will have to attend case conferences as a priority, for example - it is important to check that the local managers really understand the model of care that is required!
• Working with the TWTs (Those Willing to Try). Do local managers seem to be building on the enthusiasm of those local staff who are keen to work in a continuity model (with all of the changes that this will make to their work/life balance), or are there signs that reluctant staff members are being drafted in to work in the initial continuity teams?

2. Scrutinising local maternity services decisions: are they designing-in continuity of carer for the future, or making it less likely?

• Focus on new staff recruitment. A key barrier to the rapid implementation of a continuity of carer model is that many staff have become accustomed to working in a non-continuity model, and have built their non-work arrangements around this. This is not an easy matter to untangle. In order to tackle this structural problem for the future, AIMS suggests that it is really important to scrutinise how new staff are being recruited. It may well be that the majority of new midwifery staff, for example, are not yet being allocated immediately to a continuity of carer team model of working. But if they are not being recruited on the basis that this is the policy objective for the local service, then this is simply storing up problems for the future, making continuity of carer for most women within the next ten years less (rather than more) likely in your area.
• Putting short-term planning into a broader context. How do the decisions being made now in terms of the creation of continuity of carer teams either help or undermine the straightforward further rollout of the continuity of carer model? You will want to scrutinise carefully, for example, the new structures that are being put in place to meet initial continuity of carer targets, and to think about whether they really make sense given your longer-term ambition. Let’s imagine an end-point goal, for example, where your whole area is covered by mixed caseload continuity teams of staff. If that is where you hope to get to, but you are starting out with a couple of continuity teams that are taking on specific groups of women from across your whole area (for example, women with existing mental health issues, women who are particularly vulnerable for other reasons, or maybe even a cohort of women who are keen to be supported to birth at home), then you will need to take into account the eventual disruption of the dismantling of these teams as you move over time to a more geographically-based team structure. Good design now must be informed by a longer-term context which is your local vision of where you are trying to get to: initial implementation plans cannot be sensibly considered in isolation.

How can we help you?

The AIMS Campaign Team is here to support local activists every step of the way with this campaign, so please don’t hesitate to get in touch with us via email at campaigns@aims.org.uk if you have any questions or would like some advice.

As part of this work, the AIMS campaign team would also like to build up a picture of how continuity of carer is being planned and implemented across England, or at least what it feels like from an activist perspective. This will really help us as we continue with our national campaigning work and as we collaborate with parallel campaign efforts being led by other groups and individuals. So please get connected with us if you are working on this issue in your own local area, so that we can all keep in touch.

You can also help us by sharing information such as tips about what campaigning strategies are working well in your area and what doesn’t work so well. And tell us what support you would find helpful. We look forward to hearing from you, and we look forward to us all supporting each other on this key issue.3