INTERIM INSIGHTS REPORT V2 Maternity Services in ... · INTERIM INSIGHTS REPORT V2 Maternity Services in Shropshire Telford and Wrekin: staff and family perspectives 1. Background

Prepared by The ELC Programme 30 August 1017

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INTERIM INSIGHTS REPORT V2 Maternity Services in Shropshire Telford and Wrekin: staff and family perspectives 1. Background Maternity care is a key priority in terms of commissioning for women and children in Shropshire CCG and in the broader Shropshire Telford and Wrekin Sustainability and Transformation Plan (STP). Better Births – a nationally mandated five-year local maternity system transformation programme is underway, and local action to better meet patient needs is required. At The Princess Royal Hospital in Telford, there is a consultant led unit plus a midwife led unit (MLU) on the same site. There is a second MLU in Shrewsbury and three further MLUs in the rural communities of Oswestry, Bridgnorth and Ludlow. There are also two community bases in Whitchurch and Market Drayton. People who live in Shropshire love having a MLU close to them and tend to get their antenatal and postnatal care there. Those who have low risk births can also deliver their baby in a MLU setting. The numbers who do this are low; around 14% of all lives births annually, with 3% of total births happening in the three rural MLUs. In recent years, there has been several high profile adverse events in the area. There is heighted public awareness and scrutiny of the quality of local maternity care; a lot of press coverage with difficult headlines in local and national newspapers, and lots of community engagement, including emails from the public supporting MLU care. Against this background, The CCG is leading a review of MLU care. The main provider Shrewsbury and Telford NHS Foundation Trust (SaFT) supports the review and senior leaders from the trust believe that the current service configuration does not align with clinical needs in the places where babies are delivered.

2. Programme design 2.1 Communities of interest This programme engaged with the following communities of interest: 2.1.1 Parents, women and their partners across the county

• Women and mothers who are pregnant or have a baby up to the age of two years living in urban and rural settings


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• Partners of women who are pregnant or have a baby up to the age of two years living in urban and rural settings

2.1.2 Staff who work in the service

Research aimed to include:

• Early Pregnancy Assessment Service (EPAS) staff

• Midwives who work in the community, MLUs and the consultant led unit at Princess Royal Hospital, Telford (CLU)

• Health visitors

• GPs

• Obstetricians

• Womens’ support assistants

• Ward clerks

• Special Care Baby Unit

2.1.3 Target numbers The target was to speak to 50 families and 50 staff; a sufficiently robust sample to undertake qualitative research and produce robust, high quality findings. The minimum acceptable sample size was set at 30 participants per sample. 2.2 Data collection methodology

Data collection was standardised using data collection templates prepared by The ELC Programme. These supported a semi structured interview with participants. The framework covered 10 touch points through the maternity journey and 4 open, semi-structured questions. Copies of these frameworks are reproduced at Annex One and Two.

2.3 Recruitment

Discovery work was conducted in settings where people are - an outreach model - whereby a random sample of people using the service currently was offered the chance to be interviewed on that day. Routes to engage people in outreach work included n field work in:

• 5 MLUs

• Consultant led unit wards

• Antenatal and postnatal clinics

• Mother and baby groups in the community

• Existing professional networks, team meetings and training sessions where maternity professionals were meeting e.g. protected learning events; team meetings


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• Email and phone contact from interested staff and parents Where outreach was conducted with groups of people, a group approach was adopted and people complete their own outreach template. The group then discussed the touchpoints and the researcher took written notes.

In a few exceptional cases, staff or parents were interviewed by telephone. Those families and staff engaging directly by email and phone and wanting to participate were offered the option to share their feedback by self-completing the form electronically. In addition to this formal, structured feedback process, a further 38 individuals submitted free text evidence to the researchers about their experiences. 2.4 Staff touch points

The following ten touch points framed discussions with staff in the formal research:

1. Relationships with families and maintaining continuity of care 2. Relationships and communication with other professions e.g. health visitors,

GPs, obstetricians, special care baby unit 3. Supporting families to plan and prepare for birth: antenatal care safety and

quality; setting expectations of birth; writing/input into birth plans 4. Supporting birth: care safety and quality; assessing risk 5. Supporting families after birth: care safety and quality; breast feeding;

supporting transition to family life - bonding with baby; becoming a family 6. Spotting and supporting parents who are struggling 7. Autonomy and professional fulfilment 8. Personal happiness and emotional wellbeing (resilience) 9. Support from immediate colleagues 10. Support from management team: personal development, education and

training

Staff were also asked:

• What is it like, supporting families when unexpected things happen?

• What is helping you to do a good job for families?

• What is getting in the way of you doing a good job for families?

• What is one thing that you would change to improve things?

The analysis of this data is reproduced at Appendix One.


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2.5 Family touch points

The following ten touch points framing discussions with women, partners and parents in the formal research:

1. Conception and finding out I was pregnant: challenges conceiving; finding out about pregnancy; tests in early pregnancy; miscarriage or losing a baby

2. Support from and relationship with clinical people: midwife, community pharmacy, health visitor, early years’ workers, GP and specialists (before, during after birth) – including experiences of continuity of carer

3. Thinking about and planning my birth: how it influences and set my expectations; personalised care planning processes; how I worked out what mattered to me

4. Expected check-ups and reviews: (before, during after pregnancy); travel to appointments

5. My birthing experience: traveling a distance; compared to what you expected

6. The postnatal experience: getting out and about; connection to parent peers; care and support on the ward and at home; breastfeeding/bottle feeding

7. My physical wellbeing: physical recovery; sustaining healthy lifestyle and habits; starting and keeping exercising; losing weight

8. Happiness and emotional resilience: coping with baby blues; depression, anxiety, post-traumatic stress disorder

9. Connection, friendship and support from parent peers (whole journey) 10. Becoming a family: bonding with my baby; family relationships and support

(immediate and extended family; partner); housing; childcare; working life and money issues

Families were also asked:

• What was it like when unexpected things happened? e.g. care experiences of urgent and emergency care; involvement and changes when there were unexpected changes to the birth plan

• What does choice mean to you and how do you balance risk, safety and choice of place of birth?

• What made the biggest difference to your experience? What mattered most?

• What is the one thing you would change or improve about your experience? The analysis of this data set is reproduced at Appendix Two.


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2.7 Analysis of free text submissions The evidence submitted by 38 individuals as free text comments is reproduced in Appendix Three. This data was cut and pasted from emails or where it was submitted as hard copy, it was transcribed. It has been archived separately from the feedback generated by the formal discovery research framework applied by the researchers to preserve the integrity of the formal research methodology. Once full data analysis is completed, this dataset will be reviewed and triangulated with the formal research data. Any additional insights or new themes contained within it will be added to the final research findings. 2.8 Data transcription All discovery research forms were transcribed to preserve parents’ and staff language and words. 2.9 Analysis strategy Data analysis mapped and themed experiences of the whole pathway from a staff and family perspective, including:

• Getting and finding out about being pregnant

• Antenatal care

• Birth

• Postnatal care

• The impact of unexpected events and changes

• Differences in care provided in rural MLUs (n=3) versus urban MLUs (n=2) and the consultant led unit in Telford

Researchers were able to compare and contrast family and staff experiences at certain points of the journey where they have a shared experience. In addition to experiences of transactional aspects of care, this research has shed light on psycho-social and relational aspects of care that impact on becoming a family, and on maternal wellbeing and resilience including:

• Being connected with and supported by parent peers

• The emotional journey; maternal mental health throughout the journey and emotional recovery from pregnancy and birth – including traumatic and unexpected birth experiences

• Becoming a family; bonding and transitioning to parenthood


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• Learning to care for and feed baby. In addition to insights into their working lives and experiences of delivering care, analysis also shines a light on the psycho-social aspects of being part of the maternity team, including:

• Personal resilience

• Working relationships across professional groups

• Support from immediate colleagues

• Support from NHS trust management

• Autonomy and professional fulfilment Having this insight and evidence helps maternity system stakeholders to understand what people perceive is adding value; working well and getting in the way of improved care and family outcomes as well as their priorities for change and improvement so that they can make the best possible decisions on the way forward.

3. Strengths and limitations of data set 3.1 Strengths of data

The number of parents who engaged in the programme (n=132) means researchers have a data set sample of 108 women from rural areas and 24 women who live in urban settings to draw upon. The rural sample is greater than required for qualitative research. The data set contains a lot of repetition. The urban sample is sufficient and in line with the programme plan.

Women were interviewed at random in urban maternity settings. This recruitment strategy reduces incidence of any personal bias towards any particular care setting.

The differences in feedback for all parts of the journey from -9 months to 2 years across urban and rural settings was minimal, which provide confidence that the insights capture what matters most.

The most marked differences between the two data sets relates to experiences of postnatal care. This is the main touchpoint where we have differentiated between care settings feedback in this report.

The staff engaged were a random sample, with exception of staff in Shrewsbury MLU where the whole team self-selected to attend the unit and talk to researchers.

Participating GPs were also a self-selecting sample.

The researchers found significant repetition of core themes across both parent and staff data sets. This should reassure commissioners that these insights are robust and data saturation was reached in this evaluation.


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1.1.1 Limitations of data

The families who presented at the three rural MLU locations were self-selecting. This sample may have a positive bias towards MLU based care, and be made up of people with a more positive experience of MLU care.

Researchers gained feedback from: three obstetricians; one nurse from the special care baby unit (SBU); one front line health visitor, and one breastfeeding support volunteer. These are small numbers.

We were unable to interview any staff from the Early Pregnancy Service. We reached out to the team leader who was on holiday when researchers were onside in the hospital and asked for an interview. Researchers received no reply.

We did not interview any family nurse practitioners who support vulnerable women nor any other specialist midwives.

We interviewed five self-selecting female GPs. There was consistency in their feedback although the sample size was small.

This means that this staff data set can most accurately be described as the opinions of midwives and womens’ support assistants who deliver front line maternity care in Shropshire and Telford.

If this data set were to be used to inform the broader Better Births Programme, it would be advisable to expand it to include wider engagement with those with specialist roles within the maternity and early pregnancy service, and to broaden engagement with obstetrics and paediatric clinicians, health visiting, early years’ practitioners and GPs.

4. Interim Findings Insights (available in full in Appendices One, Two and Three) are triangulated and interpreted in this interim evaluation report. 4.1 Programme participants 4.1.1 Families with lived experience in the last two years A total of 132 parents with a child aged two or under participated in this phase of the programme. 108 lived in rural settings and 24 in urban settings. In addition, a further 37 families submitted free text evidence by email or in writing to the researchers. This did not follow the data collection protocol used in the main research. It has been transcribed and analysed separately and will be triangulated with formal research findings.


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4.1.2 Staff with experience of delivering care in the current system A total of 85 staff participated in the programme. Figure two summarises their roles. 54 of participants work in urban settings (MLU or consultant led unit) and 31 in rural settings (MLU or other community based). 40 participants work mainly in MLUs and 14 mainly in the consultant led unit. 27 work mainly in other settings. Figure two: roles of staff participating in research Role Number of participants

Early pregnancy assessment service (EPAS) staff

0

Midwives 56

Women’s care assistants (health care assistants)

10

Health visitors 1

GPs 5

Obstetricians 4

Special care baby unit (SCBU) staff

1

Childrens hospice nurse 1

Breast feeding volunteer 1

Housekeeper 3 Clinical manager 2

TOTAL 84

4.2 Current experiences of maternity services This part of the report is divided into:

1. Emotional maps 2. Qualitative findings about the maternity journey 3. What matters most to people bout maternity care

In this interim report, section 4.2.2. is complete. 4.2.1 Emotional maps Emotional maps are a visual way of illustrating participants’ feedback and show the journey and the ups and down.


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Family experiences across rural and urban areas are largely similar apart from birth and postnatal care where there are differences. These are described below. The maps reflect these differences. Families in urban areas

The early days of pregnancy are characterized by a mix of emotions. Amongst those where nothing unexpected happens, emotions are often positive – even if the pregnancy is unplanned – although women may still feel anxious and overwhelmed. Where women require investigation or additional help and support early in pregnancy, some report feeling patronised. Families also report GPs being unhelpful. Relationships with clinicians – mainly midwives – are generally very positive. Some families report consultants being abrupt and ‘scaremongering’ them; although others report positive relationships with consultants. Generally experiences of planning and preparing for birth – including planned antenatal care are positive; with staff described as helpful, thorough and reassuring and appointments generally on time. Those who work report antenatal care being a bit of a ‘juggling act’ and a few women mention getting mixed messages from staff. Generally, birth itself is regarded as a positive experience; although for some it is traumatic – especially when unexpected things happen. Those based in urban settings do not mention any challenges around reaching their place of birth nor anxiety linked to that. However,


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for this group, postnatal care is a far less positive experience, with wards described as busy and chaotic; the experience ‘too clinical’ and women feeling isolated and ‘pushed out’ of the ward as soon as possible. Women do not blame postnatal ward staff for this. They feel it is system/resource rather than a relationship problem. Families in rural areas

Experiences of women in rural areas largely mirror those in urban areas with the exception of birth and postnatal care. Women in rural areas have the added anxiety and pain that comes from traveling a distance to hospital in labour. After birth, both groups report significant negative impact on their physical and emotional wellbeing. Those who feel unprepared for this – because they had less proactive antenatal care or missed out on classes – report that being unprepared can make it worse. The rural cohort had generally experienced postnatal care in an MLU and their experiences were extremely positive, with MLU postnatal care described as exceptional; peaceful; relaxing; reassuring and a ‘sanctuary’. Mum friends were important and a great source of support in both rural and urban communities. It is clear from this discovery work that having well developed networks of mum friends is protective and support recovery from birth; smooths the transition to family life; builds parental resilience and helps new mums cope and keep well. Often antenatal and postnatal care facilitate connection and making mum friends – who often become friends for life. Becoming a family is generally a positive experience; although for some it is a shock and they feel nervous.


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Maternity staff

The emotional map presents the qualitative feedback from staff in a visual way as a journey of highs and lows through the touchpoints in their journey. The map illustrates that for staff, the journey is full of ups and downs currently. Whilst they enjoy good relationships with families and this is a highlight of their work, and they feel very supported by their immediate team and colleagues – a fact that is maintaining their personal resilience in the face of significant change and challenge within SAFT and the maternity service more broadly - relationships with colleagues beyond their immediate team are more fractured; and many people feel unsupported by management. This is more pronounced – although not limited to - amongst staff based in MLUs and the community than those who work solely in the consultant led unit. Staff report that antenatal and postnatal care are now very time pressured, and whilst in the past they delivered great family centred care, they feel this is changing as a result of changes made. Birth is still a high point for most; although the unpredictable nature of birth; unrealistic expectations and a sense of being under-resourced get in the way. Whilst some staff have maintained a sense of control over their working lives, many feel they have no voice and no control at all. This is undoubtedly impacting on their emotional wellbeing and resilience. It is the underlying driver for staff reporting they wish to leave their jobs. It also helps explain high rates of absenteeism and sickness, which the picture this data paints suggests may be manifesting currently.


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4.2.2 Qualitative findings about the maternity journey The key messages emerging from thematic analysis for each touchpoint are summarised here: 4.2.2.1 Conception and finding out I was pregnant The scope of this touchpoint was: challenges conceiving; finding out about pregnancy; tests in early pregnancy; miscarriage or losing a baby. Only families were asked about this aspect of the journey. Families had a range of experiences related to conception. Some fell pregnant easily; others had experienced challenges. Some had experienced infertility treatment and some one or several miscarriages. Some fell pregnant more quickly than expected. For others it took longer than they hoped. For many people, finding out they were pregnant invoked mixed emotions. For some, it was a shock – even if it was planned and hoped for. Most people reported a mix of emotions. This reminds us that the journey of becoming family invokes strong and often mixed emotions right from the start and this impacts on the whole experience. Families told us they had mixed experiences of unexpected events in early pregnancy. Sometimes staff was really supportive and thoughtful. Sometimes staff did not appreciate the distress ladies felt when unexpected things like miscarriage happen. Families told us that unexpected experiences early in pregnancy impact on their whole pregnancy and future pregnancies. They often leave ladies feeling anxious for a long time into their pregnancy journey. They told us that midwives’ support during the antenatal period in particular helps them regain confidence and manage anxiety. They said that empathy and understanding from all NHS staff whenever unexpected things happen early on is important. 4.2.2.2 Relationships between families and maternity teams; maintaining continuity of care The scope of this touchpoint covered relationships with: midwives, community pharmacy, health visitors, early years’ workers, GPs and obstetricians before, during after birth and experiences of continuity of carer. No families talked about community pharmacists. The three main groups families talked about relationships with were: midwives, GPs and consultant obstetricians. The insights summarised here describe both what families and these three key staff groups told us about the relationships with each other.


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Relationships with midwives: women told us that being cared for by a small team of midwives who knew them and supported them consistently made a huge difference to their experience of care. Women found it very reassuring to see a familiar face – especially close to birth and when unexpected things happened at any point in their journey. Whilst if they had full continuity from one midwife, it was great, many families did not necessarily feel that they needed to be cared for by the same midwife. They reported that being cared for by a team of midwives whose care and support was consistent and based on the same philosophy of kind, compassionate care worked well. Families living in both rural and urban communities told us they already experience continuity and that they value it highly. Having a named midwife did not appear to be assuring continuity. Families talked about the support and women’s care assistants provided to them in postnatal care settings and how much they valued their support with breast feeding and caring for baby in the early days. Midwives assistants told us that they got greatest professional satisfaction from supporting ladies they knew and had relationships with. Most wanted to work in a maternity system that values relationship centred care and continuity highly. Changes in working practices were compromising continuity and their close relationships with women. Relationships with GPs: families and midwives both reported mixed relationships with GPs. Some found their GP helpful and engaged. Some women struggled to see their GP and when they felt needed a GP’s help. Some felt that their GP was not really interested in their medical problems when they went to see them. Some community midwives worked closely with GPs and knew them well. Others struggled to engage GP colleagues and to get tasks done that only the GP can do e.g. prescriptions for iron supplements. This frustrated midwives. Some GPs who participated in this research explained they felt they lost touch with their women patients through pregnancy because midwives lead maternity care. They sometimes did not even know their patients were pregnant! This was corroborated by some women reporting that they went straight to the MLU and bypassed their GP on finding out they were pregnant. GPs did not necessarily see this as a bad thing as they acknowledged midwives are great at what they do, but they felt they were rapidly losing their clinical skills because they were no longer involved in maternity care. They also found it frustrating because once baby was born and after the six-week check, they were back in the lead, supporting the family again without fully understanding what had gone on before. GPs did not feel very closely connected with health visitors, and recognized that with most families, they were not heavily involved. One GP had a different experience and had met monthly with health visitor colleagues. Another had close relationships with local midwives. This was facilitated by the fact they were based in the same building. Some GPs wanted midwives to be able to take on some of the tasks that they had to pick up during pregnancy. Most wanted better ways of staying involved and in touch so that when their support was needed, they knew what was going on and it was easier to pick up with the family once the midwifery service stepped down.


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Relationship with consultants: families had mixed experiences of relationships with consultants. Some described their consultant as ‘fantastic’ – others as ‘challenging’. In some cases, this was because the family had different ideas about the birth they wanted to the birth recommended by the consultant. Sometimes it was about the way the consultant behaved and consulted with them. In many instances, women reported feeling they had no choice. Consultants and registrars who took part in the research talked about these challenging conversations from their perspective too. They recognized that building relationships with families could be difficult as generally they only got involved when things were not going to plan. This meant they often had to develop rapport quickly and often under tense circumstances when emotions were high. Most consultants felt there was always the chance to share decisions with families, and that was what they always aimed to do. 4.2.2.3 Relationships and communication with other professions Only staff were asked about this. The scope of this touch point was relationships with other professionals the maternity team liaised with to support families they were working with and supporting. The main groups that maternity professionals talked about were: Relationships with triage service: MLU midwives in particular reported difficult relationships with the triage service. They described it as a battle to get women seen. Some felt that triage staff questioned their professional judgement and took advantage of the fact that they often had a woman with them and so could not say what they wanted to say when talking to triage on the phone. Some reported that women also felt uncomfortable in triage; as if they should not be there. Members of the triage team researchers spoke to did not mention these issues. Relationships with GPs: Midwives described mixed relationships with GPs. Some had good relationships and liaised with GPs regularly. This was easier in rural locations where there was a smaller community and clinicians knew each other. Some described GPs as dismissive and talked about it being a battle to get prescriptions – with GPs sometimes refusing to write prescriptions. Some also had challenges getting GP appointments for their women. They found this frustrating as midwives perceived the woman was still the GP’s patient. It also took up a lot of time – especially in urban areas where relationship with GPs were more distant. GPs participating in this research reported less problems with their relationships with midwives. As described in 4.2.2.2, they feel quite removed from and uninvolved with the maternity journey, and this may explain why some do not engage with midwives. Relationships between MLU and consultant led unit (CLU) teams: relationships between staff in the MLU and consultant led unit were described as “them and us” by staff. This is exacerbated by the perception that the CLU “takes” MLU staff, but there is no reciprocity when MLU is busy. There is also a sense that CLU


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management do not understand what MLUs do. One member of staff described the behaviour of managers as “bullying” towards MLU teams. Those working in rural MLUs also feel there is inequity and that “Telford have been given everything for their ladies”. Relationships within the consultant led unit: Both midwives and obstetricians reported good working with relationships with each other and with colleagues. Midwives who were new to working on the CLU e.g. those transferred at short notice from MLUs found it hard to quickly get up to speed and find out who was who. There had been little formal induction; although some reported this was changing gradually. Registrars felt well supported and able to ask for help and advice when they needed it. There were indications that working relationships could be strained when the unit was close to capacity. For instance, when SCBU had no staff available and a baby needed to be delivered that required a neonatal intensive care bed. Twelve hour shifts were perceived by a consultant to be helping to build closer working relationships between doctors and the CLU team; although registrars reported that current shift patterns took their toll on their personal life. One member of staff explained how there had been a big fuss about a shared coffee room, and that she personally found it very useful as she had got to know people whilst sharing a coffee or lunch in the shared facility. Relationships within midwifery teams: most staff report that relationships with their immediate team are positive. This is discussed further at paragraph 4.2.9 4.2.2.4 Thinking about and planning my birth The scope of this touch point covered: how having a birth plan influences family expectations amd the degree to which current birth planning support and processes feel personalised to the individual woman. From a staff perspective, it covered thoughts on; antenatal care; risk management, safety and quality; experiences of shared decision making and staff perceptions of the impact of having very specific expectations of birth on family experience, and experiences of providing support with birth planning. Families told us that it often works well when they keep an open mind about what they want. Almost all the families participating in this research told us that something unexpected had happened to them at some stage of their pregnancy, birth or post-natal experience. How staff responded to and supported them through unexpected things made the biggest difference to their experience, and helped them get back on track more quickly.


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The midwife and others discussing their options with them when things changed; being connected with other parents and exchanging experiences helped them feel better prepared and get back in control. Many ladies felt that, in reality, they had little choice about place of birth because clinical risk assessment dictated they had to be in hospital. However, families were very clear that choice and their birth plan did not start nor end with the delivery of their baby. Choice included antenatal and postnatal care and support. Midwives perceive that they are good at supporting women to consider their options. Women corroborate this. They also say women often have very definite ideas and they feel there is a lot of misinformation around, including in the media. They perceive that it is becoming more difficult to support women well during the antenatal period due to changes in the way care is being provided, with less time for antenatal classes for example. They report women feel let down that MLUs are closed and that this limits birth choices and is disrupting birth planning. Some women corroborate this. 4.2.2.5 Planned check-ups and reviews The scope for this touchpoint was planned care before, during after pregnancy), including thoughts on travel to appointments. Families generally reported good experiences of antenatal care. Women reported especially liking having their antenatal appointments at their local GP surgery. Having flexibility and appointments that fit in with work makes life easier during pregnancy for those in employment. Antenatal check ups with midwives were reassuring and exciting for ladies. Families especially valued good explanations and time for discussion of options as well as antenatal activities and classes that supported connection with other expectant mums with similar birth dates. Families and staff told us that in Telford, Shropshire and Wrekin, transport is a really important factor in their decisions and choices around birth and maternity care. People worried most about travelling to their place of birth when they were in labour and about birth before arrival. Because those who had to travel to the consultant led unit were usually also the ladies at highest risk, both staff and families worried that if more people were travelling and there was no or limited access to midwife services locally in case of emergencies, birth outcomes would get worse. Staff feel that unless women have experience of Telford, those in Ludlow and Oswestry are likely to opt for Wrexham as it is closer if they want a hospital birth. For both staff and families without private transport, centralising services meant big issues getting to work or routine appointments and unplanned maternity care as well.


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Staff report there is not enough time for home visits and because they have less time, staff worry things are being missed (see 4.2.6) Antenatal classes are additional to routine care. Staff report they are no longer able to do group work with women; although women tell us groups really adds value; especially by helping them connect with mum friends and prepare for and build realistic expectations about birth. Staff perceive there is a need to improve antenatal care now. Midwives also feel review processes are prescriptive and that there is a lot of ‘box ticking’. Some midwives feel scared of missing anything and fear repercussions and litigation, reflecting a very risk averse culture, which is also highlighted in 4.2.10. 4.2.2.6 Spotting and supporting families who are not coping Researchers only asked staff about this touchpoint. Maternity staff define struggling differently. Women’s care assistants talk mainly about issues related to breastfeeding and coping with emotions in the postnatal period. Midwives focus more on psycho-social issues and safeguarding concerns. Midwives who work in the consultant led unit see spotting families struggling as more of a community midwife role. Housekeepers working on the wards recognized that sometimes women spoke to them rather than the midwives because they were a more constant presence on the ward. They spotted women not coping and informed midwives. The team on the postnatal ward of the consultant led unit support a lot of families who are being supported by social services where there are safe guarding concerns. These families do take up a lot of the ward team’s time and also cause them stress and anxiety – especially when they get visitors and staff do not know exactly who the visitors are. The things that helped maternity teams to spot parents who were not coping were: being a close knit who support women together; being able to refer women to specialist midwives when women were struggling, and continuity of care - knowing families and spending time with them. Some community midwives feel that home visits help them spot problems. One special baby care nurse reported that she felt sometimes parents find it easier to speak to other parents with the same lived experience when they are struggling. Having Bliss volunteers working with the unit really helped staff to support families struggling. One health visitor reported that although it was challenging, this was a part of her job she especially enjoyed.


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GPs reported that they did spot people struggling at the six week check. Some GPs reported that it could be difficult because the woman may not always recognise that issues they think the baby is having e.g. with feeding, is actually their not coping. Midwives reported that as a result of changes in the care model being implemented, their experience of this touch point was changing. Some said they now had less time and short visit was not enough to spot that women were struggling. They were concerned that problems would be missed. Other said they could spot problems still, but they did not have time to offer additional support and follow up when they did. 4.2.2.7 The birthing experience The scope for this touchpoint covered: traveling a distance; how the birth was compared to what the family had expected and staff perceptions of risk assessment, care safety and quality. Regardless of where they gave birth, most families participating in this research reported a good experience of birth itself. Knowing the midwife who supported birth enhanced the experience, but even when they did not know their midwife beforehand, most people said that staff was supportive during birth. 4.2.2.8 The postnatal experience The scope of this touchpoint from a family perspective covered: getting out and about; making connections with parent peers; care and support on the postnatal ward or MLU and at home; support with breastfeeding/bottle feeding; transition to family life and bonding with baby. From a staff perspective, this touchpoint covered care safety and quality; supporting breast feeding and caring for baby; supporting mum’s recoverey and the transition to family life. Many families told us that good postnatal care was the thing that made the biggest difference to them quickly becoming a happy, healthy family and their transition to parenthood. Both staff and families told us that the more medicalised the birth, the more support families needed afterwards with recovery - both physical and emotional – and to get things on track with feeding baby. Staff and families reported that when families leave postnatal care too soon, they often experience problems with feeding baby and/or mum not coping and adjusting as well to motherhood. This can mean baby ending up back in hospital needing medical support; mum taking longer to heal – emotionally and/or physically, and less bonding between mum and baby, which has long term implications for both. Staff and families told us that five aspects of postnatal care matter most:

• Really good support with breast feeding


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• Having a safe space and support to reflect on and process the birth experience – especially when it has been traumatic for the mind and body e.g. an emergency caesarean or other difficult birth issues

• Supporting bonding and connection between baby with mum and with the rest of the immediate family (partner and siblings)

• Meeting and connecting with other ladies who often become life-long friends and a source of ongoing support

• Transitioning to motherhood with confidence.

Feedback from staff and families suggests that the main impact of good postnatal care is to reduce NHS service use out with the maternity service e.g. acute paediatric care; time spent special care baby unit; supported needed from general practice and health visitors; child and adult mental health services further down the line. They said that the upfront investment in postnatal care improves mums’ and childrens’ health and resilience in the long run. Those who had experience of postnatal care in MLU reported very good experiences. Those who had experience of postnatal care in a hospital ward setting felt staff did their best, and had very little time to support psycho-social aspects of support like breastfeeding and maternal emotional recovery. Staff who worked on the postnatal ward wanted to spend more time with mums, but were mainly focused on their medical needs due to time constraints and on mums on the ward under social care supervision where there were safeguarding concerns. This small group of families took up a lot of postnatal ward staff time and energy on the consultant led unit. Most of these families had no medical reason to be on that ward. 4.2.2.9 Maternal physical recovery and wellbeing The scope of this touchpoint covered: physical recovery; sustaining healthy lifestyle and habits; starting and keeping exercising; losing weight Some women report feel physically unwell during the antenatal period and report problems with feeling tired and not sleeping as well as nausea. Those who develop complications feel well looked after. The main time when women have issues around their physical wellbeing is in the postnatal period. Giving birth is a shock to the physical body and system. Those who had missed antenatal classes felt less prepared for what would happen. Many women had to recover on some level from birth. Those who had significant medical intervention – including a caesearean or episiotomy - or a physical injury like a tear – reported being in a lot of pain and requiring a lot of support to get about and look after their baby and get feeding. Having other children at home that needed looking meant staying in the MLU ward have them space and time to start their physical recovery well.


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Some women were able to take control and invest in their own physical recovery by quickly exercising and 4.2.2.10 Maternal happiness and emotional resilience The scope of this touchpoint covered: coping with baby blues; depression, anxiety, post-traumatic stress disorder. The emotional journey is very personal. It begins early in pregnancy and continues. From finding out - whether the baby is very much wanted and planned or whether baby is more of a surprise - emotions are high and often low too. Women report feeling grumpy, emotional, scared and anxious as well as elated, happy and excited. In the postnatal period, many women report feeling emotional during the first few days. They see this as normal; although those pregnant for the first time say they do not always anticipate the impact on their emotions. The level of intervention the woman has during birth impacts on emotional resilience after birth. Emotional resilience and recovery in the early period is influenced by having time and space to recover in an MLU ward; meeting mum friends on the postnatal ward; open access to family and their being able to visit easily; support from midwives and help to get about and cope with baby. This support supports bonding and becoming a family. During the more extended postnatal period emotional resilience and recovery is influenced by a number of factors, including: whether the woman knows their midwife - has a ‘named midwife’; the level and quality of professional help they get during this extended time; the support they have from family and how their partner responds to baby arriving; whether they have connection and support from mum friends and whether they get out and about with baby. Those who get good postnatal care and support report that it has made a big difference to their emotional resilience and becoming a happy, confident mum. 4.2.2.11 Connection, friendship and support from parent peers The scope of this touchpoint was the whole maternity journey. Parents can become lonely after birth of their child, which impacts on their emotional wellbeing. Families told us that being friends with other like-minded parents has a huge impact on their lives and ability to cope. The mum friends that women make during pregnancy, at birth and afterwards on postnatal wards and in baby groups last a life time.


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Ladies who have close friends with children the same age support each other emotionally and stay resilient. Ladies told us, if it wasn’t for their mum friend, they did not know where they would be. Mums with friends from earlier pregnancies did not always feel the need to make a lot of friends in subsequent pregnancies. Social media and Whatsapp helped friendship and connection between mums to blossom. Antenatal classes and other organised activities support and facilitate parental connection. Staff told us that they recognised the value of parental peer support. They reported that because of new ways of working, they were no longer able to support groups and many had been stopped. Sure Start and activities organised by community organisations like churches help connect parents. A big difference between the postnatal ward in Telford hospital and MLUs was that in hospital, mums did not interact. They stayed behind their cubicle curtains and did not make friends with others on the ward. Both staff and families commented on this. In MLUs, in contrast, most mums reported they had made friends on the ward whom they still met up with. 4.2.2.12 Becoming a family The scope of this touch point covered: bonding with my baby; family relationships and support with immediate and extended family and partner; housing related issues; childcare, working life and money issues. Like other parts of the journey, becoming a family is a very personal experience, which can be a very happy time or be fraught with difficult emotions – especially when it is a first baby; parents are older and ore used to life without a baby. Parents told us that having support from family and good professional support during the postnatal period helped them become a family. Great postnatal care – in particular care provided in the MLU helped. Women especially mentioned how the MLU environment helped them to bond with their baby; transition to motherhood and introduce siblings to the new baby, which made that transition easier and supported close relationships between siblings and the new baby.


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4.2.2.13 Autonomy and professional fulfilment Only maternity staff were asked about this. Midwives and women’s care assistants are often very passionate about their work. However, increasingly many feel they have very little control over their working lives. This is new in the last 12 months. Whilst a few say they do feel they have control, most midwives working in the community and MLUs feel they have limited autonomy because the future is very uncertain; they feel they have had no voice nor say in the future and they feel disengaged from and let down by senior managers. They also complain that they have been kept in the dark about changes. They have mostly read about what is going on from social media before they hear it from their employer. This is especially difficult because they are dealing at the frontline with the backlash from ladies on the front line when units close and appointments and birth plans have to be changed. This leaves staff feeling hopeless and angry. Frontline teams really want to feel involved more. They often feel they would come up with great solutions to some of the challenges the system faces if they had a voice and the chance to contribute. Not feeling in control is impacting on their work and home lives and on their emotional wellbeing, health and happiness. They also report low morale. They feel unappreciated for the work they do. They feel frustrated with working life and feel that they are under time pressure and less time is impacting on continuity of care and creating a conveyer belt experience; that their work is mainly box ticking and paperwork is getting in the way. They feel they are letting their ladies down – especially in areas where there have been MLU closures. They also say the way call outs and on call arrangements are managed is getting in the way of great - and even safe - maternity care. Staff talk about “being pulled out” of their day job to work in the consultant led unit, and how disruptive that is. Working in different and unfamiliar environments is difficult and some staff feel it is risky. GP participants report that they do not have any sense of control over their care of women during pregnancy. They lose contact with them often until the six week check – unless something goes wrong. Then they feel they do not know the context. A number mentioned they felt they were becoming deskilled.


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4.2.2.14 Personal happiness and emotional resilience families were asked about emotional health and this is reported on separately. Maternity staff were asked happiness and personal resilience. Not feeling in control is impacting on midwives’ work and home lives and on their resilience, emotional wellbeing, health and happiness. Some staff talk about the highs and lows they are experiencing. Many staff reported their resilience was waning in recent months, and that the changes had evoked a very strong emotional response. The changes and how they have been managed has left staff feeling helpless. This loss of control at work was taking its toll on family life and leading to strained relationships between team members – as well as staff worrying about each other. A number of staff who were further on in their career reported they wanted to retire early. Younger staff were actively looking for another job – in some cases outside maternity care. One member of staff mentioned there was supervision if staff wanted it, but there was little evidence of robust processes being in place to help maternity staff deal with and process their emotional labour. They relied predominantly on informal support from colleagues to do this. This contrasted with the experiences of hospital doctors. They recognised the impact of their work on emotional wellbeing. They felt they were well equipped with training as part of registrar rotations and positive coping strategies they learnt in their training, including reflective practice. Likewise, GPs felt able to cope. 4.2.2.15 Support from immediate colleagues Only staff were asked about this touchpoint. Maternity staff reported very close relationships. Many teams described their immediate colleagues as “family”, with some teams having worked together for decades. Staff reported that support from their colleagues was keeping them going at the moment. The changes had had a negative impact on team working. There were now fewer team meetings; a sense of “them and us” across different parts of the maternity system, which had been there before and was more marked now. Staff also reported they felt they had no voice nor say, which was impacting on relationships with colleagues.


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4.2.2.16 Support from management Only staff were asked about this touchpoint. Although experiences were mixed, some staff felt supported by their immediate managers and generally relationship with immediate managers were closer and more supportive. There was a difference in experiences amongst staff who worked mainly in MLU environments and those who worked more on the wards. Staff from the wards reported that managers ‘rolled their sleeves up’ and helped in busy times. MLU staff did not feel they got that kind of hands on support from managers. In contrast, frontline midwives and womens’ assistants in particular felt very uninvolved by management who were perceived to be inaccessible, unsupportive and ‘concerned with higher issues’. For instance, many staff working in MLUs reported they had never met senior professional managers. Doctors talked about positive clinical leaderships within the unit from senior consultants. Midwives and other nurses talked about a number of behaviours they observed in senior managers and within the current system that they found especially difficult:

• Skewed system measures: families and staff both recognized that the main focus of measurement within maternity services was on delivering babies. Some staff also felt that current metrics did not capture what was happening and adding value in MLUs, and felt that current ways of measuring were ‘feeding the machine’. Whilst delivering babies safely was vitally important and a must do, families and staff told us that delivering babies was not the end of the story. They said that the care and support families get both before and after birth is vitally important to family outcomes; health and happiness in the long run. They said they would like to see the maternity system focus more on “becoming a family” – with safe delivery of babies an essential aspect alongside great antenatal and postnatal care

• Lack of family centred thinking: staff reported that management thinking was not family centred

• Lack of understanding of MLUs and postnatal care: linked to the previous point, staff perceived senior managers did not understand MLUs and they value they added to the maternity journey. Staff felt that good postnatal care was vitally important - yet often undervalued in the current maternity system because the tariff is mainly focused is on delivering babies and that is where the money flows to as well. This frustrated staff not involved in birth because this payment system made some of the work they were doing in the community and in MLUs largely invisible – even though they saw and heard


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from families the difference it was making to family life and outcomes. This was exacerbated by the way things are measured right now

• Lack of support and value of staff: Staff felt senior managers’ behavior showed that they did not support nor value staff. They felt let down

• Poor communication: staff felt there was no communication between senior managers and the front line. They were really angry that they read about very significant issues like closures of MLUs in the local press or on social media before they were informed by their direct line or senior managers. Managers also reported they were in the dark about closures. Staff reported that sometimes women coming for appointments knew more than they did about what was going on

• Hierarchical decision making: staff reported decision making was very hierarchical and they were not involved in nor consulted about decisions and any changes. Changes felt imposed and they had no opportunity to offer solutions

• Guideline and protocol driven decision making: staff reported that current clinical risk thresholds limit midwife led birth. The culture was described as risk averse and staff there was a sense of staff not being able to stray from the guidelines. Staff also found it frustrating when there was inconsistencies when the system reached breaking point e.g. babies above a certain risk threshold had to be transferred to another hospital when there was capacity, but when there was no system capacity, the SCBU would be contacted and asked to take babies that were higher risk than the ones who had just been transferred.

These behaviours mean that trust between the senior management and front line teams has been broken and staff believes that despite the review being underway, decisions about the future of MLUs have already been made. Families also reported that they believed decisions had already been made. One participant recognized that in the past the focus had been on getting things done and said that senior managers now recognized that reflection was key to improvement. SaFT had brought in The Transforming Care Institute and 1,000 staff have been through the process learning how to do improvement. 4.3 What matters most Analysis available end of September


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5. Discussion of findings This interim report evaluation sheds light for the Midwife Led Unit Review Board on the whole maternity journey and the way that current service configuration and MLU activity is impacting on outcomes. The findings are set out below. Appendices One, Two and Three (available end September) provide more detailed insight generated from participants’ feedback and are available for those who need more detail. 5.1 What impact does the current care model have and how is it changing? This research has uncovered ten impacts of the current care model and key areas focus for the MLU review team. They are:

1. Early pregnancy support 2. Maintaining continuity of care 3. Sharing decisions when clinical risks are raised 4. Relationships within and between professional tribes 5. Delivering planned care 6. Getting women to their place of birth on time 7. Post-natal care on CLU ward 8. Post-natal care on MLU wards 9. Building social networks amongst mums 10. Improving professional engagement

5.1.1 Early pregnancy support These insights remind us that pregnancy, birth and postnatal care is a very personal and emotional journey. It starts with conception and finding out; a touchpoint that can change the dynamic within relationships with family and partners; invoke strong emotions – both positive and negative, including fear and anxiety as well as happiness and excitement. This is especially true when a woman has a history of miscarriage or other issues in early in pregnancy or when it is a first-time pregnancy. Midwives, partners and family support can help mitigate emotions when the experience is difficult. Staff being empathetic if a woman experiences or has experienced miscarriage is critical and staff need to recognise that having had a miscarriage or things gone in a previous pregnancy casts a shadow and impacts on future pregnancies too.


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Midwives being available, supportive and empathetic during the antenatal period is especially important to a woman with a history of unexpected events, including miscarriage. These ladies may need more support than others during the antenatal period to help build confidence and manage their anxiety, which they may get from MLU teams currently. When a woman has a history of miscarriage, having to wait 10 weeks for a scan feels like too long. Several women reported paying privately for scans earlier. Making sure that there is empathy from all staff for women with a history of unexpected issues early in a previous pregnancy, and understanding of how that history impacts on their emotions and need for support during antenatal care and subsequent pregnancies is key to service improvement. 5.1.2 Maintaining continuity of care Relationships with midwives are generally good and continuity has been working well up in Shropshire, Telford and Wrekin with small teams that share similar values and practice consistently delivering continuity. There are indications that recent changes in working practices is compromising womens’ relationships with midwives and continuity. These insights suggest the continuity in the current system is highly valued and needs to be sustained in any new care model to maintain quality. Insights into experiences of GP care are more mixed, and this research reveals both sides of the story. Some women perceive GPs being disinterested in their maternity experience. Some GPs report they feel disengaged because they effectively lose their women patients for the term of their pregnancy and then get them and the baby back at six weeks post birth. Whilst GP recognise this is not necessarily a bad thing from a clinical perspective, it disrupts continuity of GP care at an important time in family life with families that the GP may care for many more decades. GPs say they are not looking for more work, but would like better ways of staying connected and of understanding the journey families have been on. They also feel they are becoming deskilled currently in relation to maternity care; something that could be important if they find themselves having to deal with more maternity emergencies in rural areas in the future. 5.1.3 Sharing decisions when clinical risks are raised Feedback from both families and obstetricians show that birth choice is a tricky subject when clinical risks rises. Though unintended, many women requiring consultant led care based on current risk stratification feel that they have little choice. There may be room for improvement around how obstetricians support conversations and discuss the risks so that women feel more in control and as if they


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own changes in decisions about birth when they are assessed as being in need of consultant led care. Linked to choice of birth place, there may also be a case for reviewing whether current risk stratification processes are limiting births in MLUs and whether – as staff perceive – a lot of the women on the CLU by choice are low risk and do not need to be there. The final report from this research will shed further light on how women weight up risk and make birth choices. This may provide useful insights to inform training for clinicians around discussing risk and choice with women. 5.1.4 Relationships within and between professional tribes Relationships between professionals are close at immediate team level in most parts of the maternity system in Shropshire, Telford and Wrekin; although the stress of uncertainty and current management approaches to change management are taking their toll on the resilience of MLU and community midwifery teams (see paragraph 4.2.2.15). Staff in the CLU report close working relationships, although there is also evidence of tensions and stress when workload impacts. There is clear evidence of opportunities for improvement in team working and building mutual respect and understanding between: MLU and CLU teams; community /MLU midwives and triage staff, and between GPs and midwives. 5.1.5 Delivering planned care GP surgeries are seen as a convenient place to get routine materbnity care. MLUs are also seen as good place to get routine care amongst those who have an MLU local to them. Midwives report that the current pressures within the system mean that there is less time for planned routine care during the antenatal period. The immediate practice response has been to cut back on the time spent one to one with all women and to stop antenatal classes, which run adjacent to clinical reviews currently. This is a “lose lose”scenario for both women and maternity staff. Staff worry that they will miss something important when women get less support. Meeting other mums and becoming friends supports maternal resilience, and antenatal classes support this.

One possible solution to maintain value and deliver efficiency gains is to change the way that routine care is provided; for instance, by introducing group antenatal


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clinics. There is a strong evidence base for this approach from the United States1. Group antenatal clinics have been shown to improve outcomes for mothers and babies compared to usual antenatal care, including:

• Women feeling more prepared for labour; having greater knowledge, less rapid repeat pregnancy, less weight gain (including in those who were obese at the start of pregnancy), higher breast feeding initiation

• Less utilization of neonatal intensive care

• More frequently optimized antenatal care

• Fewer pre-term births (33% risk reduction); higher average birth weights – including amongst infants delivered pre-terms

• Increased self-esteem; decreased stress and social conflict in the third trimester; lower social conflict and depression one year post-partum most especially amongst women who report high stress levels at presentation.

Much of this research was conducted in areas with high levels of socio-economic deprivation and amongst women from communities who are at highest risk of poor maternity outcomes, which suggests that the model is likely to work in those who face less inequality. Combining routine planned clinical care with antenatal education and psycho-social support in a group clinic could support continuity and maintain and consolidate the close relationships that women and midwives in Shropshire Telford and Wrekin both value. A feasibility pilot undertaken to explore adoption of this moel in the UK found that it was feasible; both women and midwives liked this model of care, and it supported both clinical and psycho-social benefits. Researchers recognised implications for training and workforce development; that it requires a strong commitment from management and those supervising midwives, and that such a change needed to be adequately resourced and managed, including managing the tension between the status quo and pushing change too fast. They recommend gradual and incremental adaptation2. The ELC Programme has supported the development of group clinics run by health visitors and childrens centre teams in Hertfordshire over the last 12 months. 1 https://www.ncbi.nlm.nih.gov/pubmed/26691105 https://www.ncbi.nlm.nih.gov/pubmed/26164694 https://www.ncbi.nlm.nih.gov/pubmed/23524175 https://www.ncbi.nlm.nih.gov/pubmed/21318932 https://www.ncbi.nlm.nih.gov/pubmed/26340483 https://www.ncbi.nlm.nih.gov/pubmed/17666608 https://www.ncbi.nlm.nih.gov/pubmed/14672486

https://www.ncbi.nlm.nih.gov/pubmed/16620257 https://www.ncbi.nlm.nih.gov/pubmed/27485493 2 http://fnp.nhs.uk/sites/default/files/contentuploads/cp_kings_gaudion_2010.pdf

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http://fnp.nhs.uk/sites/default/files/contentuploads/cp_kings_gaudion_2010.pdf


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Internal evaluation has found both quality and efficiency gains:

• Efficiency gains; with 10 minutes or 22% professional time saving per review. This equates to minimum three whole time equivalent health visiting posts across Hertfordshire

• Quality improvement because the social context of group reviews may support more accurate assessment of child development

• More joined-up, family-centred care planning across health and early years

• Improved staff experience through an improved clinic working environment with less repetition and reduced professional isolation

• Improved family experience in a more relaxing, child friendly, less stressful assessment environment, where children can mix and play with peers

• Parent benefits from feeling less alone; sharing experiences and advice; building peer connection and friendships that increase parental resilience; the same benefit of learning from professionals, coupled with gaining learning from peers; seeing their child playing with others - sometimes for the very first time

• Increased parental awareness and use of children’s centre activities and programmes.

Group clinics of this type could also support delivery of planned postnatal care. Staff also reporting that it is becoming more difficult to spot families who are struggling because there is less time and continuity. Changing the way that planned care is organised into group clinics could sustain quality around this touchpoint as well; offer peer support to women who are struggling, and provide a different way delivering specialist midwifery support alongside universal support as well. There is little evidence from this research that the maternity system in Shropshire Telford and Wrekin is making full use of volunteers as members of an extended maternity workforce. Given the significant levels of engagement amongst women across the county, there is a great opportunity to harness this energy and build a volunteering strategy that involves the community becoming part of a refreshed maternity care model. Co design events in September provide the opportunity to test whether this is something the community would embrace.


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5.1.6 Getting women to planned place of birth on time In relation to birth, whilst experiences are already good, some clear improvement issues emerge related to supporting birth in a rural county. The first relates to supporting women to estimate how far their labour has progressed so that they can reach their place of birth in time. This is important regardless of whether MLUs are open locally because those who need to get to the CLU for a consultant supervised birth need to do that because of their clinical risk merits consultant involvement so they need to arrive in time. Currently MLU staff support women to estimate by seeing them in person or speaking to them over the phone. Community midwives already report challenges accessing triage support for their ladies at the CLU. When researchers discussed how things could change, initially staff felt it would be challenging to help women more accurately estimate as everyone woman was different. However, on reflection, they saw that potentially there would be better ways of supporting triage with the goal of getting women to their planned place of birth in time. This had two aspects; helping women to recognise their personal pain thresholds prior to labour so that they were vigilant for early signs of labour if their paoin threshold was naturally higher, and access to timely advice and support once labour has started. The use of Skype and Facetime; having a dedicated person supporting triage remotely and building ways of working in rural areas that involve on call midwives, GP specialists, paramedics and even volunteers who act as specialist ‘maternity first responders’ were all discussed during interviews with staff in rural areas as possible improvements. The second aspect was having local contingencies in place to step up when it becomes clear women cannot make it to their place of birth in time. This provides the opportunity to build on existing assets like MLU wards and the hospital in Wrexham and explore whether paramedics, midwives and GPs could work together more closely on such contingency arrangements. One simple solution suggested by a midwife was that on call rotas were based on where midwives lived rather than being linked to their place of work so that they were closer to the area their on call covered.


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This is an important element of the local care model where there is room for fresh thinking and innovation, and exploration of learning from existing rural maternity delivery models. 5.1.7 Postnatal care on the consultant led unit (CLU) In relation to postnatal care, research reveals a significant difference in the casemix, experience and quality of postnatal care delivered in MLUs and on the CLU postnatal ward. MLUs are specialists in holistic postnatal care and recovery. CLU postnatal care is more acute and clinically focused. In many cases, women experience both because they are transferred to an MLU ward from the CLU ward to complete their postnatal inpatient stay, reflecting the fact that the CLU ward limits its focus to women and babies who care needs are complex and who are in need of more intensive clinical support. However, there is a second group of women supported on the CLU postnatal ward. They are women being supported by social services where there are safeguarding concerns. Ward staff say that these families take up a lot of their time and attention. Yet, these families do not necessarily need to be on the ward for clinical reasons. It may be worth looking at the enablers and barriers to this group of families being cared for and supported in the MLU environment rather than on the CLU. This would potentially free up a lot of staff time on the CLU postnatal ward to support women with more complex clinical needs and their babies. This may help improve the experience and outcomes of families on this ward. Furthermore, CLU and MLU postnatal ward teams can learn from each other and work together on improvement. For instance, CLU teams can explore with MLU teams how to create the right conditions to support women to interact and connect on the ward. In stark contrast to the MLU postnatal experience, women in the CLU postnatal wards do not interact and become friends. This is a missed opportunity as this connection can lead to life-long friendships that support maternal resilience; perinatal mental health and recovery from birth trauma. Given most women in the CLU ward have had more complex, medicalised births and these insights show that those women benefit most from great post-natal care, it is even more important that their post-natal journey starts well in the CLU and they get both the clinical and psycho-social support they need to recover fully.


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It also makes sense to discharge women as soon as possible to a less medical environment where they can continue recovery and gain the benefits of specialist postnatal support described in this research as soon as possible . It is important to note, given current trends in births and demographics of mothers that the need for great postnatal care is likely to become even greater the more medicalised birth experiences become and the more frequent surgical interventions are. This means that based on current trends, if anything, the demand for great postnatal care is going rise in the future. 5.1.8 Postnatal care in midwife led units (MLUs) The postnatal care provided in MLUs is supporting maternal recovery and providing a strong foundation and launch pad for becoming a family. The maternal recovery journey is a physical and an emotional one. Those who undergo surgical intervention cope with recovery from surgeries that they were not part of a birth journey, women would take weeks off work to rest and recuperate from. In the early days post birth, these women may require a lot of help and support, mobilising and caring for their newborn baby. This is what MLU teams provide during MLU post-natal care. There are also parallels around women’s emotional recovery. Some women describe their birth experiences as “traumatic”. The ELC Programme has found previously that alongside post-natal depression, some women suffer from post-traumatic stress disorder (PTSD) after birth. PTSD does not fully manifest until three months after the trauma, and so women who are traumatised may need emotional support over an extended period. Obstetricians researchers spoke to recognized tis and had a PTSN clinic in place. Early support to come to terms with the experience may also be vital to recovery, and the stories from women interviewed for this research suggest that the time and space to reflect and come to terms with the trauma of birth and recover is a significant benefit afforded by MLU postnatal care. NICE guidance3 confirms that the link between great postnatal care, breast feeding rates and maternal mental health, and there is no doubt that MLU based postnatal care is also delivering these benefits. What appears to be getting in the way at the moment is that the impact of postnatal care is not measured systematically nor valued within the maternity tariff nor within

3 https://www.nice.org.uk/guidance/cg37

https://www.nice.org.uk/guidance/cg37


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the Shropshire, Telford and Wrekin maternity system currently. This may be skewing the way the system values and prioritises different parts of the maternity journey. Because SaFT only cares for women up to six weeks after birth and most of the benefits of great postnatal care are realised in other parts of the NHS e.g. general practice; acute paediatric care; CAMHS and adult mental health services or in the community e.g. health visiting, early years support, social care – and usually at a later date, it is unsurprising that SaFT senior managers perceive that current resource allocation does not reflect clinical needs it is responsible for meeting. The current tariff then reinforces that, with money following birth. However, those taking a whole system approach can focus on the benefits of investing in great postnatal care and recognise it as an investment in the future health, wellbeing and resilience of families in Shropshire, Telford and Wrekin, which will endure through early years and potentially for decades to come. Recognising this unintended consequence of the current system frames the challenge for MLU reviewers differently, and provides a broader context for discussions about the future of MLUs, given their core strength currently is their specialist skills in delivering highly impactful postnatal care; a service funded from the maternity budget with impact and outcomes that are realised outside of that pot of money. This is why it is critically important that commissioners – both health and local authority – lead this MLU review. Once decisions are made and investment priorities agreed on the value of post-natal care, and the role of MLUs in its delivery, then it may be important to recalibrate and join up the system to focus on becoming a family from -9 months through to early years and to put in place family centred outcome measures that assess impact on that broader outcome as part of a balanced commissioning outcomes framework that extends beyond birth and into early years. 5.1.9 Building social networks amongst women A very strong message from women is that having a strong network of ‘mum friends’ and family around them protects resilience; supports recovery and becoming a family. Maternity care across the whole journey can be designed to promote and nudge social connection between parents with babies of similar birth dates. Facilitation of these connections can be deliberately designed into the maternity system at every opportunity as the stronger mums’ social networks, the more protected mums will be from loneliness, perinatal mental health issues and the more


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supported they will feel coping with family life. Increased social support may also make families less reliant on primary care, maternity, social care and early years’ support in the longer run. We have described opportunities to re-engineer routine care towards group clinics and care which promote peer connection. Group clinics could simultaneously reap efficiency gains in professional time and thus offer a “win win” solution on many levels. Working closely with early years’ providers on a group clinic development agenda could preserve or even enhance and build continuity further. Working with mum volunteers to re-engineer care could ensure community engagement, contribution and sustainability. 5.1.10 Improving staff engagement Engaging GPs in the design of any emerging care model and Better Births will be important. This research shows they will also be affected in a number of ways by changes in the maternity care model. Despite significant investments being made by SaFT in engaging teams in quality improvement, most maternity teams feel they have very little autonomy in their working lives, and that there is little focus on improvement within their organisational culture. This is a change. Autonomy in particular has declined in the last six months. This is partly because staff perceive senior management has been behaving poorly and not communicating with them during a time of controversial service change and partly because of a perceived culture of intolerance of risk and box ticking that is limiting professionals’ ability to apply their professional judgement, including delivering babies in the MLU setting. Some staff reported that the CLU is “full of low risk women”. Some perceive that this is because of how risk assessment processes work. Others feel it is because low risk women choose birth in the CLU over the MLU because it is modern and a lovely facility. This research is yet to uncover what women think and how they makes choices. More in depth insights will follow in the final report that will explore this further. Currently many maternity staff feel disempowered, hopeless and angry. SaFT will have an uphill battle to rebuild trust with its staff. To heal the rift, it will be critical to involve staff in the development and planning of the way forward as part of the review.


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It will also be important that staff get feedback about what this research has found so that staff can see that their voice has been heard and that commissioners and SaFT are responding to what they are saying. The same is also true of the maternity community, including campaigners; some of whom believe decisions about the future of MLUs have already been made. The first step in rebuilding trust will be recognising shared history (much of which is contained in these insights) and asking staff what they feel needs to be done to improve things. The workshops planned in September 2017 will start this process and SaFT and the CCGs can continue engagement with staff in addition to and beyond these workshops. The ELC Programme is enabling broad engagement by supporting the CCG and Healthwatch to run co design workshops independently, using the findings from this report. SaFT team leads can also be supported to do the same with staff if they would like to. Those trained in QI skills could lead some of this work. This research provides SaFT management with detailed 360 degree feedback about how the current management approach is impacting on those at the front line. Reflecting on what staff are saying and thinking through how to respond and improve the way that change and improvement is being managed will be critical to the success of this review and future work around Better Births. This includes improving staff involvement in decision making as well as embracing different ways of measuring impact that focus more on psycho-social alongside clinical outcomes related to becoming a family. 5.2 What good maternity care looks like in Shropshire Telford and Wrekin

Based participants feedback, we have synthesised and described the characteristics that participants feel make up good maternity care. These are presented as fifteen “design principles” below:

1. The system focus is towards “becoming a family”, with great antenatal and postnatal care valued alongside safe births

2. Staff empathy and understanding of the impact on women of unexpected things happening early in pregnancy and of miscarriage should be an always event

3. Relationship centred system design including continuity of care and supporting midwives to work in small teams is a really valuable aspect of our current maternity service that this maternity system needs to preserve

4. A maternity service where GPs feel interested and involved in supporting ladies who are pregnant


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5. Consultants and families sharing decisions about birth and feeling able to have positive and sometimes challenging conversations about the risks and birth options is a good thing

6. A good personalised approach to care planning includes a flexible birth plan that covers antenatal, and postnatal care and recognises that unexpected things are very likely to happen to most families at some point in their journey so that families are open to discussions about different options when things change

7. Because of the rural nature of this community, having local routine care and local contingencies in place to deal with maternity emergencies safely across Shropshire, Telford and Wrekin is critical to great maternity service.

8. Really responsive triage that provides quick, effective, personalised reassurance when unexpected things happen and that supports women to judge their progress in labour as accurately as possible so they get to their chosen birth place in time are vital design features of our maternity triage service – especially in rural localities.

9. Having flexible antenatal appointments close to home, with time for discussion, good explanations and the chance to meet mums with a similar birth dates is key to a good antenatal experience.

10. Good, safe birth experiences in Shropshire Telford and Wrekin need to be preserved

11. Good postnatal care really matters. Even though most of the benefits are realised in other parts of the NHS system, because it helps build the foundation for happy, healthy families from the start, investment in great postnatal care that delivers the following benefits is really important for community resilience:

• Really good support with breast feeding

• Having a safe space and support to reflect on and process the birth experience – especially when it has been traumatic for the mind and body e.g. an emergency caesarean or other difficult birth issues

• Supporting bonding and connection with mum and the rest of the immediate family (partner and other children)

• Transitioning to parenthood with confidence

• Meeting and connecting with other women who often become life-long friends and a source of ongoing support.

Design needs to recognise that good postnatal care is even more important

after a highly medicalised or traumatic birth – especially one that involves surgical intervention or physical injury.

12. The design of all routine antenatal and postnatal maternity care and environments, including wards, should support mums to interact, meet and make friends with others with children of the same or similar birth date.


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13. How midwives and the maternity workforce feels really matters. The design of the maternity system needs to out midwives feel in control again, and involve staff in decisions, the planning and improvement of maternity care in Shropshire, Telford and Wrekin.

14. We very quickly need to design services and different ways of working that restore maternity staff resilience in Shropshire, Telford and Wrekin.

15. Maternity money flows, tariffs and outcome measures should all align better with what matters and support the creation of healthy, happy families alongside delivering babies so that other parts of the maternity journey are valued too. We need to measure different things within our maternity service in different ways, and in particular measure the things that staff and families have told us matter to them in these insights (see Section 5.4).

5.3 What is supporting and getting in the way of improvement Shropshire, Telford and Wrekin maternity services? Analysis to follow in final report 5.4 An emerging maternity outcome measurement framework for families and staff This work suggests that currently the maternity system is distorted because all the focus, measurement and attention related to birth. This work suggest that to better reflect what matters to families and staff, the overarching outcome that should drive maternity system is ‘becoming a family’ rather than a safe birth. If the focus of the system was shifted in this way, system focus may be more balanced, with the value of good antenatal and postnatal care more visible and important alongside a positive, safe birth experience. This has implications for commissioner collaboration because ‘becoming a family’ goes beyond the bounds of the maternity service and is supported by early years services, which are commissioned by local authorities. This suggests that shared family centred outcomes across services that start during pregnancy and carry over into early years would prove helpful and support smooth transition, collaboration and family centred working. These person centred outcomes and accompanying measurement processes do not replace clinical outcomes and other prescribed measures. They can be collected alongside standarised metrics. They can be incorporated into existing care and support planning, and staff appraisal and review processes. With good measurement system redesign, they can be aggregated at population level and used to support service improvement and commissioning.


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Making the assumption that ‘becoming a family’ is the focus, and based on analysis of this data, the long list of outcomes that matter most to families are:

1. Relationships with maternity staff 2. Relationship with GP 3. Making ‘mum friends’ 4. Being confident and prepared for birth (delivered mainly through antenatal

care and peer support) 5. A positive memory and a safe birth 6. Recovering well from birth (delivered mainly through postnatal care and peer

support) 7. Coping well when unexpected things happen 8. Emotional wellbeing and resilience 9. Physical health 10. Getting out and about 11. Coping with caring for baby; parenting 12. A strong family bond

The long list of outcomes that matter most to staff are:

1. Relationships with families; continuity 2. Relationships with immediate team 3. Relationships with maternity colleagues 4. Autonomy and professional fulfilment (feeling in control) 5. Support from management 6. Contribution (having a voice and being involved in service development and

improvement) 7. Personal resilience

At the co design events, participants will help create a short list from these outcomes so that community perceptions of the priority outcomes can be identified. 5.5 Survey design The findings from this report were synthesised to produce a twenty-question survey designed to test the emerging findings with local community. The final version of the survey is provided at Appendix Four. This survey was not mobilised.


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6. Next steps

There are two further elements to this programme planned:

6.1 Co design events with the maternity community

In September, 6 co design events will run to enable local people to hear what we have discovered so far and help decide the way forward. There will be a ‘launch event’ on 07 September and a series of satellite workshops around the county. The ELC Programme will run the launch and first satellite; present emerging findings and and coach Healthwatch and CCG engagement leads so they can run later events.

6.2 Feedback to affected people

Best practice into engagement4 and research into success transformation5 both show the importance of closing the feedback loop and sharing emerging findings with affected people. Shropshire CCG has a database of people who have provided their email and want to be kept in the loop about this work and the findings. The ELC Programme highly recommends that the CCG publish outputs from the process in full and as a summary and signpost those affected by the change to these resources – including the database of people who have engaged so far.

For queries about this interim report, contact:

Georgina Craig

Director, The ELC Programme

Tel: 07879 480005

Email: [email protected]

4 https://www.england.nhs.uk/ourwork/pe/ipe-rep/ 5 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3479379/

mailto:[email protected]

https://www.england.nhs.uk/ourwork/pe/ipe-rep/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3479379/

Documents

INTERIM INSIGHTS REPORT V2 Maternity Services in ... · INTERIM INSIGHTS REPORT V2 Maternity Services in Shropshire Telford and Wrekin: staff and family perspectives 1. Background