Annie Francis asks whether it is an opportunity for change or 'just another report'
Looking around the other members of the National Maternity Review team as we sat down to our first meeting on 23 April 2015, I wondered if they were all feeling as daunted by what lay ahead as I was.
I needn't have worried; after an intense and brilliantly facilitated session, we finished the day with a clearer sense of the task ahead and even more important - a rough idea of where to start! At the beginning of the day, we were asked to reflect on what people tend to assume about national reviews (which can limit their impact) and what we wanted to achieve in order for this one to be thought of differently.
I was not alone in voicing my main anxiety, that it would be just another report that would be full of ideas for implementing change which might cause a flurry of interest and then join lots of other such reports sitting on a (digital) shelf gathering dust. I also wondered if we would be united in recommending a future service that had continuity of carer for the whole pathway, including birth, as its aspiration - my passionate ambition - or would we end up putting it into the 'it's just too difficult to implement' box?
Sitting in that first meeting together, we came up with a long list of the assumptions we anticipated could be made about this review - including 'it won't change anything', 'it's just about closing units', 'it will mean more rules and regulations', 'it's politically motivated', 'it isn't related to reality' and - the biggest of all for me - it will be another 'missed opportunity'. What we wanted to achieve was an equally long list - that it must be evidence based; that it will resonate with both users and staff; that it will be seen as thoughtful and considered; that it will help to break down barriers and bring about change... that it will be both implementable and implemented.
With the launch of the report1 in February 2016, whilst there have been some of those anticipated negative responses, what I am more struck by is the willingness on the part of so many to suspend judgement. Rather than simply defaulting to a cynical 'it won't work' attitude ... often without even bothering to read the detail ... it has felt to me as if the reception has on the whole been positive, as if there is a broad recognition and acceptance of the scale of the challenge and a sense of wanting to give the actual ideas themselves a chance.
I think one of the reasons for this greater willingness to engage is the widely shared view that we have to find a way to move on from the fragmented, medicalised and technocratic system we have been burdened with for too long now and which has been thoroughly discredited as the means by which we improve the provision of the 'personalised, kind and more family friendly care' described in the review...in my opinion, the fact that so many dedicated staff still manage to give that level of care within the current maternity service is a testament to their ability and desire to do so despite the system, not because of it!
People have also recognised and applauded the genuine effort - which is down to the determination of those conducting the review - to go out into the workplaces and local communities up and down the country, as well as to engage through social media, asking everyone to contribute their views about the service from their perspective and listening carefully to the messages that came back.
And what did we hear? The message, loud and clear, that women and their families - those who are the raison d'etre for the service want more continuity of carer. They also want their care to be safe, they want to be treated with respect and they want to be given all the information they need to be able to make properly informed choices. What the evidence suggests is that all of those things will be so much easier to achieve if we can reform the way we provide care so that more women can get to know just one or two midwives, working within a small team, instead of meeting a steady stream of different faces at every appointment, which is so often the norm within the current system.
The challenge of how we provide this, however, is contained within one of the other messages coming through from the listening exercise, this time from midwives ... that being constantly on-call and working in caseload teams, within the current system, is generally too demanding, leads to burn out, disrupts their family life and is too difficult to implement on a large scale.
So, there we have it, the same old conundrum we've had for decades; we know what women want, we know that the evidence on outcomes supports this way of providing care and we also now know it is actually more cost effective. But, how on earth do we provide it without the midwives, who need to be at the heart of this change, paying too high a price, or at least having the perception that that is what will happen?
The key for me is the phrase 'within the current system'. What the Review does differently this time is to be explicit about the need to provide care through different models, acknowledging that a more radical approach is needed to move away from the current episodic nature of care provision, each episode often managed by a different health professional within a hierarchical and bureaucratic organisational structure.
Building on the lessons from past successful models of providing continuity (of which there have been many), there is a clear message that we have to be braver about how we implement what we know works. As a priority, we need to develop the leadership and build the structures to ensure that these ways of working have the support and energy from across the whole landscape of maternity provision ... from the national bodies, from the royal colleges and from those who commission and provide the service.
This is crucial in order to securely embed these different ways of working so that they are no longer at the mercy of a relentless short-termism. Successful caseload or home birth teams are closed down and community based care often reduced as soon as there is a financial challenge or a change in senior management or an inability to recruit because midwives grow weary of being endlessly pulled in to cover other areas (usually labour ward).
Over the past few decades, whenever we have tried to implement more caseload models or provide greater continuity in other ways, we have mostly done so using the large hierarchical and bureaucratic organisational structures which already exist. If this attempt is to be any different, we have to finally recognise that trying to fit round pegs into square holes simply doesn't work. One of the core recommendations of the Review is that the NHS needs to come up with new ways of delivering the service, which are much more focused on the community and which cut across organisational boundaries.
Without being too prescriptive or dogmatic about sizes and shapes, the proposal is for providers and commissioners to operate as local maternity systems, with the majority of care being provided in small community hubs, which ideally will also be home to other family orientated health and social services - provided by a range of statutory and voluntary agencies.1 The key principle is that the community should be the default place to provide care and that different organisations within the hubs and across the local maternity system should have shared clinical governance and information processes agreed between them to provide seamless care which is focused on the woman and her family, not on the system itself.
In order to test these models robustly we need to encourage those CCGs who are successful in becoming 'maternity choice and personalisation pioneers',2 to involve clinicians and others from across the whole pathway (whether NHS or independent/third sector) - midwives, doctors, support workers, health visitors - the people needed to implement these ideas, as well as the users of the service. Then together these pioneer CCGs and the organisations working with them need to have the freedom and confidence to put their ideas into practice with tangible support and practical assistance from the centre.
The repor t is unapologetic in stating that improving continuity of carer is 'not an optional luxury'1 and that to improve on all the other indicators, such as quality and safety, we have to improve this one first and foremost. Yes, it will be challenging and no, it won't happen overnight, but thinking through some of the solutions (as proposed in the Review) should start now and should not be put off any longer. We have a clear mandate from the women who use the maternity services that they want continuity and therefore we have a clear duty to work out how we are going to provide it. The rather dismissive attitude of some providers, who in the past have turned around and said to commissioners in effect, 'Sorry, we can't do that, it's not possible', should no longer be tolerated, then hopefully the culture that allows it, the commissioning process and the tariff will all be reformed to make that response unacceptable in the future.
The various recommendations - and the suggested ways to implement them - contained within the 126 pages of the Review are all about taking a different approach, one which challenges everyone to think outside the box, to set aside the rather limiting and unhelpful silo mentality and to genuinely reach for a more collaborative way of working.
It is impossible to cover all the recommendations in this one article and I encourage you to go to the report itself to get a proper understanding of the many different ideas contained within, including some potential game-changers such as the focus on multi-professional working, the rapid resolution and redress scheme, and the NHS personal maternity care budgets.
If you are reading this article as someone interested/involved in the maternity services in some way then my question to you is this - are you ready to engage with the ideas and proposals set out in the Review to make them a success? I hope your answer is yes, because to be ultimately successful in changing an entrenched status quo, I think it will require everyone who uses the maternity service as well as everyone who works in it to put aside their preconceived ideas and prejudices and to make an individual effort to get involved and genuinely try to make these ideas work.
My sense at the end of a very intense, challenging but ultimately rewarding process was that, for all of us who took part, there was a quiet optimism that the Review would have some practical and long lasting impact. As one way of trying to ensure that, the report includes Annex A which is a summary table of recommendations, the 'owners' of those recommendations and a proposed timeframe to implement them.1 In the end though, history will be the judge as to whether this report, this time around, was - finally - the one that didn't get relegated to a shelf but was the catalyst to genuine and long lasting change.
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