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Publication - Advice and guidance

Continuity of carer and local delivery of care: implementation framework

Published
14 January 2020
Directorate
Children and Families Directorate
Part of
Health and social care
ISBN
9781839604584

Framework to enable maternity services to access useful tools, resources and information to implement continuity of carer and local delivery of care, and track progress.

View supporting documents Supporting documents

Implementation Framework

This implementation wheel best represents the experiences and learning from the EABs and reflecting models outlined by The Health Foundation (2017) and Audit Scotland (2016). The following sections outline what EABs found helpful at local level, alongside some key messages and lessons learned.

Implementation wheel showing the experiences and learning from the EABs and reflecting models outlined by The Health Foundation (2017) and Audit Scotland (2016)

Initiating Change

Preparation: Before starting the implementation, getting the ground work right at the start really helps later on.

Communication and engagement with staff and service users is key and cannot be emphasised enough! There are many ways to engage with staff, and a variety of different methods will be needed. Meetings, buzz sessions, newsletters, organisational development sessions, question boxes, internal intranet pages and one-on-one chats should all be considered. Hearing from staff working in the new model of care or even buddying up with a unit of a similar size can be valuable to understand practicalities, answer questions and make the model real for staff. Ensuring that staff have the opportunity to input and shape changes locally is a major part of ensuring success. Engage early and regularly with the partnership structures and staff side representatives in your area.

Explicit, visible support and commitment to new models of care from the senior leadership team, at Director and Chief Executive Officer (CEO) level, as well as including partnership/staff side to support implementation is crucial for success. Starting to think about the key people to get engaged and starting to make connections both inside and outside the Board to make sure the right people are involved in the implementation. This is the start of a journey that will shape the future of maternity services for years to come.

Before initiating change, the EABs undertook a scoping exercise to understand their baseline position. Process mapping current services helps to engage staff and identify potential barriers at the beginning of the change process.

A key way to engage staff at all levels is to ensure that they are fully aware of the key evidence in relation to the benefits of continuity of carer on outcomes for women and babies. It is also helpful to share the research evidence available about the positive impact on job satisfaction of continuity models of care for staff.

At a board level EABs found it helpful to identify where their starting point is and obtain baselines in terms of:

  • current models;
  • workforce – both numbers and also staff readiness (surveys, cultures);
  • current outcomes;
  • current levels of continuity; and
  • feedback from women.

At a team level gather baseline data from the current population demographics for the area and the characteristics of the population health (see the monitoring tool) as well as the skills and make up of the teams.

Creating a clearly defined project plan is an essential part of implementation and without initial scoping at this stage, and gathering baselines, it is difficult to identify key milestones, goals and the trajectory towards achieving the stretch aims. Each Board will be asked to produce a trajectory based on their current starting position with the goal of full implementation. Boards may wish to focus on rolling out continuity to sections of the Board area and gradually building up the number of women receiving a continuity model of care. Alternatively, a Board may wish to focus on delivering a continuity of care model to an entire Board area, then gradually building up the rate of continuity received within that model.

Were there any resources that were helpful?

1. Focus on one small area/locality or a particular group of women

Key Messages:

Board areas can be segmented in different ways, based on caseloads, demographics, patient flow or General Practitioner (GP) practices.

Getting to know the community that the continuity of care team is going to be based in, and the demographics of the current and future pregnant population in that area can help. Some areas may choose to test continuity of carer with a defined group of women or building on an existing team, for example, women living with social complexity and deprivation; or women with significant clinical complexity requiring obstetric led care throughout pregnancy, such as multiple pregnancies and women with diabetes.

The first team will be implementing not only continuity, but how to set up the service. This takes time but their testing will produce all the learning for the following teams with regard to: engagement, what support is required and what infrastructure needs developing. This team will have the greatest learning so keep a record of how they do this.

It was really valuable to involve the women and families from the local area in design of service for the locality. The Scottish Health Council are a great support in engagement work.

http://scottishhealthcouncil.org/home.aspx

What worked?

  • Understanding the local community, making links and learning where services are currently available and where they are accessed. This supports meeting key people e.g. GP Practice Managers, health visitors, partner agencies, voluntary and community organisations representing and supporting women and families, wider health and social care teams and leaders;
  • Building innovative models between rural areas and the referral maternity units developing Standard Operating Procedures (SOP), guidelines and feedback on experiences;
  • Taking into consideration long travel distances in remote and rural areas, and finding innovative ways to bring midwives from the referral hospital into a rural team;
  • Encouraging and supporting more local births in remote and rural areas to improve continuity of carer;
  • Equipping staff with all necessary items to facilitate caseloading, e.g. mobile phones/iPads/Doppler Fetal Monitor/Community bag/Jackets/Fleeces/stethoscopes/Blood pressure (BP) monitors, baby scales and bilirubin meters for each team. Implementing a small number of pool cars to address transport issues for some staff;
  • Having more than one project lead, e.g. separate for Neonatal Transitional Care, Alongside Midwifery Unit and Continuity of Carer, ensures continuous leadership and overview throughout implementation phase. Covering annual leave and sickness to maintain momentum of project implementation;
  • Identifying lead obstetric and neonatal medical staff to support the implementation process.

What didn't work well?

  • Focusing on the previous year's caseloads rather than current and potential future caseloads when identifying an area covered by a team;
  • Staff not being involved in co-producing the model;
  • Teams that started before the infrastructure to support them was in place, e.g.,transport, equipment, IT, office space, clinical space;
  • Developing rotas that were inadvertently not compliant with required guidance – consult with staff side and HR;
  • Not considering the need for backfill for staff joining the continuity teams and therefore putting additional strain on remaining community and hospital core staff, this can lead to resentment and stress;
  • Using rostered model didn't work well in some areas for community based continuity teams, as their local context required them to cover core duties in the maternity unit. Providing intrapartum care for women not in their caseload. This had the potential to reduce the amount of time continuity midwives had to provide care for women in their caseload.
Case Study
Larkhall was chosen as our first pilot site due to the caseload size fitting into the 1:35 real-time caseload for midwives. The area had a very small proportion of women who lived in Lanarkshire who chose to birth elsewhere. We realised after a few months that the caseload size was too small and added an additional joining area to the team. Blantyre and Hamilton were then chosen as our next two teams as the staff share office accommodation and can support each other through the transition to the relationship based continuity model of care.

What do you wish you had known or had access to?

  • The Impact of changes to GP Contracts having unintended consequences for hubs as primary care teams are expanded and developed. Identifying space to work from has been challenging in many areas, knowing how to access non-NHS venues and property, or getting access to spaces is challenging and time consuming;
  • Understanding the workforce and population profile better;
  • National workforce advisor;.
  • That it is possible to begin the continuity journey by initially focusing on women who are likely to benefit the most from continuity of carer or where there is a team keen to start implementing, while planning for full Board roll-out. For example women living with social complexity and deprivation; women with complex medical care needs; or to begin by setting up a home birth team;
  • That HR and staff side and partnership organisations can be a source of guidance and information on organisational change approaches, staff views and issues around working hours, on-call rotas and pay.

What would you like to share in terms of approaches and why?

  • Understanding the workforce and population profile; this cannot be left to teams to solve and Board and leadership support was found to be invaluable;
  • The team needs to be agile as this is an ever changing environment and susceptible to other service changes;
  • It is important to recognise the starting point of your particular Board or locality;
  • Having more than one project lead, e.g. three leads, one for NTC, one for AMU and one for continuity of carer, ensures continuous leadership and overview throughout implementation phase was found to be helpful;
  • Phased implementation for NTC;
  • Liaising with other Health Boards, learning from others;
  • Teams trialling different rota models, including on-call, rostered, etc. Taking into consideration external factors such as locality and distance;
  • Have regular meetings between project leads, managers and staff side and partnership organisations representatives.
Case Study
In Campbeltown Community Midwifery Unit (CMU) some women may make their own way to Paisley for birth, often travelling in very early labour due to distance, in these cases it is not practical for the primary midwife to travel 3.5 hours to follow the woman in early labour. One of the midwives working in the Royal Alexandria Hospital (RAH) in Paisley has joined the Campbeltown team and meets women who are coming from Campbeltown. So far this has met with very positive feedback. Oban CMU and Dunoon are arranging with RAH Paisley for their newly qualified midwives to spend a week a month in Paisley which again will support continuity from the team when the primary midwife is unable to be there.

Were there any resources that were helpful?

2. Wider Team Involved

Key Messages:

Continuity of carer represents a fundamental change in delivery of care, and therefore communication and preparation with staff is key to managing concerns and achieving buy-in.

This not only impacts on midwives, to support the change it involves the wider multidisciplinary team.

EABs found it important to involve the wider team in terms of:

  • Establishing a Best Start Project Board chaired by a senior leader/Director supported implementation. Engagement of women as part of the wider team is crucial for success.
    • to address barriers and challenges;
    • this includes IT, estates, workforce planning, HR, staff side, learning support to support the development of new infrastructures and routes for clinical governance.
  • The wider multidisciplinary team:
    • the linked consultant;
    • health visitors/Family Nurse Partnership (FNP);
    • social work;
    • maternity care assistants;
    • administrative support;
    • community mental health teams;
    • GP, Practice Managers;
    • voluntary and third sector;
    • women/service users.

EABs found it helpful to develop ways of sharing learning and progress within the Board, between teams and within teams- these communication routes will be essential as more teams develop.

EABs also found it important to engage the support of, and have regular engagement with, experienced HR and staff side and partnership representatives on all aspects of the change process; understand and apply the principles of organisational change and take into account Agenda for Change and other employment relations guidance.

What worked?

  • Drop-in sessions facilitated by managers, team leaders and staff side and partnership representation;
  • Clear communication and staff engagement on a regular and on-going basis – with teams, service users, hospital based midwives and partner agencies;
  • Engaging the midwives early, e.g. organisational development sessions for midwives, sessions on the evidence for continuity of carer and the lived experience of continuity midwives;
  • Peer support for leaders and managers;
  • Identifying bases/areas to work from;
  • Meeting with key people in the local community e.g. GP Practice Managers, health visitors, third sector, wider Integration Joint Board (IJB);
  • Joint expertise and buy-in at senior level;
  • Early and ongoing engagement with RCM and other staff side colleagues.
Case Study: Wider Team Working
In Argyll and Bute, which is part of NHS Highland, many women receive their care in Glasgow. The midwives in Argyll have started having quarterly meetings with the Glasgow core team to develop relationships across Boards. Geographically linked Consultant Obstetricians from NHS Greater Glasgow and Clyde are now using Attend Anywhere to work with communities across the Argyll area by holding virtual clinics. This required getting planning, management and eHealth in both Boards involved. Honorary contracts have been put in place, but easier ways to move across boundaries would be helpful.

What didn't work well?

  • Staff engagement at the very early stages, as it wasn't until pilot teams started that there was better information to share on how the new model operates;
  • Engagement with primary care was not always easy as there is so much change already taking place in primary care settings and teams. For example - access to accommodations for teams was a particular challenge in this context;
  • There was not always a wider understanding amongst colleagues that this is transformational change and takes time.

What do you wish you had known or had access to?

  • How to get the right level of Board buy-in and ownership of the change;
  • Knowing how to ensure progress and barriers were being shared at the right level within the organisation;
  • National job description for caseload and core midwives; national guidance on key issues relating to on-call, on-call payments etc.

What would you like to share in terms of approaches and why?

  • Developing effective communication structures that support the team to have the autonomy to develop.

Were there any resources that were helpful?

3. Go where the energy is

Key Messages:

Identifying change agents within the workforce was found to be helpful, and in the initial stages asking for volunteers has made all the difference to changing hearts and minds. Offering opportunities for taster sessions in early teams can really help the change process, as those that were initially reluctant can become the greatest advocates.

- Fisher's Process of Transition curve explains how people respond to change through defined phases that are followed in succession until they accept the change.

Make sure that the first team have a lot of support for their wellbeing as there will be many 'eyes' watching progress.

What worked?

  • Expose midwives to new areas; offer trial periods to all midwives to test out new ways of working;
  • Starter packs for teams going out into new model.

What didn't work well?

  • Cross boundary – Boards working at different levels of implementation caused challenges for women and midwives. This was also evident when teams within an EAB were at different points of implementation. It is important to manage expectations and keep everyone informed;
  • It is important to understand the culture locally as this can impact negatively on experiences;
  • It is important to listen to staff, ensuring that there is a vehicle for feedback and facilitating networking. Mutual respect and professionalism needs to be paramount;
  • During the transition phase of working between two models there was a need to keep a watchful eye on potential staff impact;
  • People basing their feelings and judgements on myths or assumptions.

What do you wish you had known or had access to?

  • Ensuring team has the right skill set – for example, caseload management, diary management and rostering, wider knowledge of GIRFEC across the whole team, as well as clinical skills;
  • Considering non-caseloading team leaders so they have oversight of their teams and caseloads, can provide an assurance role, lead on education, support clinical supervision, peer review, caseload reviews and child protection oversight;
  • Midwifery passport detailing skills and competencies of the holder – considering support for any midwives who are revalidating during this period of change;
  • Addressing culture, mutual respect and values in order to build confidence and trust across teams.

What would you like to share in terms of approaches and why?

  • Don't use the same people all of the time and expect these people will change over time.
Case Study

NHS Lothian In NHS Lothian, we put up posters seeking volunteers to join the team. This allowed us to identify our change agents

https://drive.google.com/open?id=1AxIr3HdHaoew826fLI42d3TYvxmIWhKy

NHS Forth Valley

Despite lots of planning it wasn’t until we were actually immersed in the caseloading model that issues we hadn’t considered were highlighted and it was only through trial and error we found solutions working with the midwives.

We currently have a ‘You said We did’ feedback sheet with questions from staff that we populate monthly and send out attached to our 'Best Start' newsletter.

Were there any resources that were helpful?

  • Skills passports (link on page 21);
  • SOP, honorary contracts (samples available from NHS Highland and NHS GG&C);
  • NHS Forth Valley staff information packs for NTC – NGT feeding/IV antibiotics FV Admission criteria for TC (links on page 21);
  • Caroline Homer C, Brodie P, Sandall J, Leap N (2019) Midwifery Continuity of Care 2nd Edition Book ISBN: 9780729587136.

4. Develop a shared vision

Key Messages:

EABs reflected that this step is often missed, but was really helpful within Boards. Women and families voices were really valuable in developing a shared vision. Engage with women and families with recent experiences of local maternity and neonatal care to focus on what matters to them.

At Board Level:

  • What is the vision for maternity services?
  • What outcomes do you want to achieve for the women and families?
  • What is the vision for the workforce and the service?
  • Is the vision co-produced and is everyone signed up to it and owns the vision?

At team level:

  • What is the teams' vision for their community, caseloads and for each other?
  • What are the values of the team?
  • How are they going to work together?
  • What tools or skills do they have to develop the culture of the team and vision for the care the women receive?
  • Manage expectations around timeframes for implementation – this is transformational change and will not happen quickly;
  • Teams are empowered to lead changes locally within the parameters agreed with management and staff side;
  • Teams can develop solutions to test, underpinned by programme management and planning support;
  • Consider goals both within the team, but also that contribute to the overall Board plan for implementation;
  • Teams work together to devise their rota and continue to test different models; this will support the impact on work/life balance and continuity offered.

What worked?

  • Team-building days to encourage the team to get to know each other;
  • Clinical supervision to support conversations, reflection and wellbeing of staff;
  • Maternity Care Assistant (MCA) based in hubs to support caseloading midwives, MCAs support the midwives in a variety of ways such as breastfeeding support, Phenylketonuria test (PKU) and additional parenting support;
  • The MCAs have electronic diaries than are accessible to all caseloading midwives to book appointment times.

What didn't work well?

  • There was not always a wider understanding amongst colleagues that this is transformational change and takes time;
  • Team leaders holding full caseload;
  • Trying to implement the model when there are vacancies;
  • Backfill for maternity leave for caseloading midwives proved challenging.

What do you wish you had known or had access to?

  • Better engagement with the whole multidisciplinary team – understand that the continuity model is not just midwife focused;
  • Understanding workforce and population;
  • Understanding that frequent meeting and revisiting is important as staff often focus on what appears relevant at the time.

What would you like to share in terms of approaches and why?

  • Ensure that unintended and intended positive and negative consequences are going to be captured to enable learning;
  • Management approach: needs to strike a balance between direction and autonomy;
  • Share the learning as you go, both nationally and locally;
  • Team leaders can provide an assurance role, lead on education, support clinical supervision, peer review, caseload reviews and child protection oversight;
  • Supervision and support is required at all levels throughout teams, including managers.

Were there any resources that were helpful?

Best Start Rapid reviews

https://blogs.gov.scot/child-maternal-health/2019/03/18/best-start-evidence/

Rocca-Ihenacho L et al. (2018). Midwifery Unit Standards. City University London

http://www.midwiferyunitnetwork.org/wp-content/uploads/PDFs/LY1309BRO-MUNEt-Standards-PRINT-opt.pdf

5. Using planning tools

Key Messages:

  • Process and skills mapping carried out at the baseline stage are important for informing this stage;
  • Developing a clear overall project plan with attached timescales and process measures is essential;
  • To individualise plans to meet population and staff needs; developing logic models/theory of change with indicators, agreed inputs, outputs and outcomes, both short and long-term help to describe the steps to achieve the agreed vision and to test assumptions was helpful. These do not have to be complicated;
  • Teams need to have ownership of their plans and be equipped with the right quality improvement skills and feel comfortable in taking on new tasks;
  • Using data to evaluate as plans develop and adjusting plans appropriately;
  • Structured oversight of the programme, including clear clinical governance structure and process was found to be instrumental for success by the EABs;
  • It is important to recognise that every Board has a different starting point, so project plans will acknowledge this and show the individual steps that the Board will take along the journey towards full implementation.

What worked?

  • Undertaking a baseline to measure progress against – for the service model, views of staff and views of women;
  • Using Project Initiation Document (PID) document and other project planning tools from outset;
  • Teams developing their own improvement plans/driver diagrams.

What didn't work well?

  • Not getting planning and project management input from the start;
  • Not developing an overall project plan from the outset.

What do you wish you had known or had access to?

  • Planning and project management document earlier.

What would you like to share in terms of approaches and why?

  • Process mapping ;this was a good way to get everyone involved in visualising current systems and barriers to care being efficient.

Were there any resources that were helpful?

  • NHS Education Scotland. Quality Improvement Zone https://learn.nes.nhs.scot/741/quality-improvement-zone
  • Programme/Project Management Tools: e.g. PID, Gant chart, 5 year step plan, Logic models.
  • Accessing a Project Management Office (PMO) or similar in your Board.

Attached are links to the Project Initiation Document and Strategic Engagement Plan NHS Lanarkshire used.

PID – https://drive.google.com/open?id=1eB7l7LIzdSGQiVvc0pNR8jrepNNShn8M

Strategic Engagement Plan – https://drive.google.com/open?id=1z4P-NPfc8ezaDdkCvUWtBCxOvN9nkI5_

6. Share learning

Key Messages:

EABs realised that it is important to capture learning as you go. The focus will be on reaching the end point, but keeping a note of the journey, what was tested, what worked, what didn't work and any unintended consequences is all important learning to log.

Peer support across Boards can also help to share different approaches and develop new ideas. Buddying up with a unit of similar size or with similar geographical challenges can help to develop solutions and learning what worked elsewhere. Regular feedback from staff and service users should also be heard.

What worked?

  • Sharing the learning as you go, both nationally and locally;
  • Using data to evaluate as plans development – adjust plans appropriately and share learning as you go through the change process;
  • Evidencing what you have done from the outset –it helps to look at the overall picture, e.g. impact of plans on workforce.

What didn't work well?

  • Not keeping a note of ideas tried as we went;
  • Engaging staff too early – wasn't until pilot teams started that there was better information to share on how the new model operates.

What do you wish you had known or had access to?

  • Accessible support for staff with access to shared learning.

What would you like to share in terms of approaches and why?

  • Ensure that unintended and intended positive and negative consequences are going to be captured and to enable learning.

Were there any resources that were helpful?

  • Local resources, for example using clinical or quality improvement expertise to present data for senior Health Board staff, maternity staff and service users.
  • NHS Lanarkshire collected data from their continuity teams. Below is the Larkhall one year on data and their highlight report to demonstrate what has been gathered and how it is informing future movement of the model through the Health Board.

Larkhall one year on https://drive.google.com/open?id=1xIx9fOmCcy3YbApKWPlGtZyXtQjsxkn0

Highlight report https://drive.google.com/open?id=1Nm6w-qtj_n3lvuuiG1b3vi8o37zrVMSb

7. Set up an engine of change

Key Messages:

In change of any sort there are people who are more engaged initially than others. The EABs found that in order to support these early enthusiasts, grouping them for peer support, linked with the key people who can practically move change forward is important – this is the engine for change.

The engine for change is the group who are visible and builds momentum by driving forward practical changes. This group will support testing and be integral in overcoming barriers and sharing wins with their colleagues. Their feedback and enthusiasm will be useful in helping others understand how the new model works in practice.

The core of the engine is the implementation team and project team working closely with the early change agents – it is also important to build up the next wave of change. People get tired and their enthusiasm can dip. Therefore it will be important that others around them can take over and carry on leading the change. Offering trial periods within teams can be a good way of exposing midwives to the new model and has proven successful in reassuring concerns, and helping them embrace the change.

What worked?

  • Expose midwives to new areas – offer trial periods to all midwives to test out new ways of working;
  • Identify change agents – EABs found that staff who were initially less enthusiastic for the change could be strong advocates once they had experienced the benefits;
  • Starter packs for teams going out into new model;
  • Don't use the same people all of the time and expect these people will change over time;
  • Bear in mind the student experience and harness their enthusiasm – ensure they have the right support and clinical support in a changing landscape.

What didn't work well?

  • Midwife resource availability for backfill was a challenge in some EABs in order to keep current model running while transitioning to new model.

What do you wish you had known or had access to?

  • Understanding that frequent meeting and revisiting is important, as staff focus on what appears relevant at the time;
  • Better understanding and knowledge of Agenda for Change (AfC) terms and conditions of employment and organisational change processes;
  • Understanding more about the concerns of the workforce about a continuity model and the barriers to change;
  • Having a whole team in place ready to go prior to developing plans.

What would you like to share in terms of approaches and why?

  • The benefit of regular communication and drop-in sessions for midwives.

Case Study

In NHS Lanarkshire, long-term staff sickness created a challenge for both early teams. This provided an opportunity for two midwives to trial caseload model of care on a temporary basis, as both were unsure they wanted to work in this new model. Both midwives embraced the challenge and have now joined Best Start teams. This is the poster used to advertise trials https://drive.google.com/open?id=1zoMPhDj_JPKvTO5q4-vrdBtKR69NRKfK

Were there any resources that were helpful?

  • RCM State of Maternity (linked previously in this document).
  • RCM Nuts and Bolts publication (linked previously in this document).

8. Distribute decision-making roles

Key Messages:

Changing the model of care can impact on where decision-making needs to sit. In order to make this transformational change, there is a balance between getting the buy-in at Board level and enabling the midwives and teams on the ground to have forums for decision-making.

Devolving decision-making and leadership to the appropriate level gives ownership of the change and promotes collective leadership and autonomy. This requires effective systems for communication and governance.

What worked?

  • Individual teams being supported to find the rota that worked for their team and given the ability to be flexible;
  • Developing a shared vision for clarity and expectations for all – at Board and team level;
  • Having a strong multidisciplinary oversight group that is visible and approachable;
  • Having structures for oversight of the programme, including clear clinical governance was helpful;
  • Using clinical supervision at team level to support the team to develop, reflect and look after the team wellbeing;
  • Using RCM local workplace representatives and the national team to provide advice on the appropriate employment relations guidance and regulations, and to explore whether new rotas being tested are compliant;
  • Using local HR departments to offer support and guidance on appropriate processes.

What didn't work well?

  • Not taking time to understand the culture locally, as this can impact negatively on experiences.

What do you wish you had known or had access to?

  • Accessible support for staff with access to shared learning.

What would you like to share in terms of approaches and why?

  • Understanding different cultures, building mutual respect and values in order to build confidence and trust across teams was fundamental for success.

Case Study

The ownership for the model, rota and improvement plan in the CMUs in Argyll, sit very much with the teams. This means that there is local variation in how teams work, often reflecting the geography and team make up. The team leads work together to support their teams to find the best way to work but come together to develop agreed parameters that they work within. Only if there are workforce or unforeseen challenges do team leaders seek additional support from senior managers.

Were there any resources that were helpful?

9. Invest in workforce development

Key Messages:

  • EABs found that training and education is crucial. Clear arrangements for backfill to release staff to undertake training, education and shadowing to feel confident to work in new ways was very helpful;
  • Regular team meetings, one-to-ones with managers and clinical supervision built in to all new team work plans worked well;
  • Monitoring and resolution of unintended consequences was found to be useful.

What worked?

  • Induction for newly registered midwives;
  • Exposing midwives to new areas – offering trial periods to all midwives to test out new ways of working;
  • Starter packs for teams working in the new model;
  • Providing focused information sharing workshops and events, such as the RCM Continuity days, the National Education for Scotland (NES) caseload management workshops and inviting midwives from existing caseload teams to come and talk to midwives;
  • Agreeing and formalising the role of core hospital midwives in supporting caseload midwives when they provide intrapartum care.

What didn't work well?

  • Cross boundary – Boards working at different levels of implementation caused challenges for women and midwives. This also was evident when different teams within an EAB were at different points of implementation;
  • Team leaders holding a full caseload;
  • Caseload midwives working in teams before their training and support needs had been identified and addressed.

What do you wish you had known or had access to?

  • Engagement with Higher Education Institutes in order to understand what they could offer for postgraduate education as well as better understanding of their preparation of undergraduate midwives.

What would you like to share in terms of approaches and why?

  • Ensuring the team has the right skill set – including elements such as caseload management, diary management and rostering, GIRFEC, as well as clinical skills;
  • Considering non caseloading team leaders so they have oversight of their teams and caseloads, can provide an assurance role, lead on education, support clinical supervision, peer review, caseload reviews and child protection oversight;
  • The benefit of supervision and support at all levels throughout teams, including managers;
  • Exposing staff to various areas they will be expected to work in a structured way – a starter pack for new teams was helpful;
  • Midwifery passport detailing skills and competencies of the holder – supporting midwives who are revalidating during this period of change is important;
  • Addressing culture, mutual respect and values in order to build confidence and trust across teams..
Case Study

Listening to midwives who change to the new model of care will help understand what is needed to prepare new teams. Using skills gap analysis and one-to-one discussions with each midwife will help identify the individual learning needs prior to becoming a caseload midwife. In NHS Lanarkshire we now commence preparation of midwives two months before the new team is rolled out. Planned Supernumerary opportunities for midwives to 'shadow' colleagues in areas of midwifery care are accommodated in order to gain experience. A midwives resource book is distributed to each midwife along with an individual skills gap analysis.

We now have a team leader who is non-caseload holding, who provides individual one-to-one supervision on a monthly basis to all staff to identify individual learning needs (1 leader = 24 midwives) people don't know what they don't know. She also provide support in areas such as child protection cases, to ensure women and families continue to receive appropriate support; gathering of monthly statistics and facilitation of weekly team meetings.

Were there any resources that were helpful?

  • Make better use of Technology Enabled Care (TEC);
  • NHS education for Scotland resources;
  • Skills passports;
  • Standard operating procedure (SOP);
  • Clinical supervision – for example, building into team meetings;
  • RCM educational resources

10. Test and Evaluate

Key Messages:

The EABs found it helpful to continue to test and evaluate any change as you go. Continually assessing whether a change is working for both midwives and women is important and making small tweaks can make big changes.

They also found it helpful to have agreed measures and an electronic method of collecting data to reduce the burden on those providing care. Don't assume that everyone has the same understanding of what is being measured.

Positive messages

  • NHS Forth Valley – midwives may not like the on-call requirement of caseloading but they ALL like having a caseload of their own women and building relationships.

Early Learning

  • Communication and staff engagement is essential
  • Workforce planning and testing the core helped with evaluation of models tested
  • Plan and do it! Staged approach to implementation has been challenging.

What worked?

  • Teams with an even number and testing the optimum team size, depending on the model being tested; for example, rostered or on-call;
  • Regular evaluations of how the new model is working, making small tweaks along the way;
  • Engaging early and actively with staff side and partnership representative organisations, and inviting partners to all key meetings.

What didn’t work well?

  • It was difficult to collate all evidence, both positive and negative, as you go along without an electronic system;
  • Some challenges when using a rostered rather than on-call model for continuity teams. This has, on occasion, meant that continuity team midwives are using a significant proportion of their hours covering care of women who are not in their team, in labour areas – this can undermine the level of continuity, and working additional hours which is likely to lead to burn out;
  • Challenge of setting up new model vs testing element of model vs getting up to full caseload. Resulted in stress and potential burnout for team;
  • Caseload midwives prematurely working in teams without always having the appropriate equipment, transport arrangements and clinical and office space, including fully functioning IT support including web-enabled mobile phones, and personal computers or tablets for each midwife.

What do you wish you had known or had access to?

  • Better understanding and knowledge of Agenda for Change (AfC) terms and conditions of employment and organisational change processes.
Case Study

Setting up a new system of service provision is not without its challenges. The Blue Team in the Clyde area of NHS Greater Glasgow and Clyde commenced at the beginning of January 2019, setting up a weekly meeting held by the team, Senior Charge Midwife, Lead Midwife, with occasional attendance by Chief Midwife and Clinical Services Manager. Attendance at this meeting is considered mandatory unless on annual or sick leave, or having been called out to a labourer. This meeting enables the team to report any challenges they have faced, and resolution is discussed and then implemented.

An action log of challenges is kept, with items removed as solutions found. Logistical items included equipment, accommodation, transport, rosters, etc., but also the development of team parent education classes, team leaflet and antenatal meet and greet sessions. Other assumptions made in the planning did not come to pass for example: women declined to be booked in their own home, preferring to attend an NHS facility, however, some were later happy to have antenatal care at home.

Several months in, a major issue became apparent. The team were over aspirational in their pursuit of continuity of carer and were attempting to provide total antenatal and postnatal care to their own caseload rather than utilising their buddy midwife. This resulted in a negative impact on their work/life balance, which could have led to burnout.

This issue was discussed within the team meeting and management reiterated that 100% continuity by the primary midwife was neither expected nor wanted, as the team had to be sustainable. The team were reassured and matters have now resolved, the team maintaining 100% continuity between both primary and buddy midwives.

Team meetings are also a time for communication – between the team, team leaders and management. Meetings provide a safe environment for the exchange of ideas, problems and their solutions. This learning can be shared with new teams going forward.

Contact

Email: beverley.lamont@gov.scot

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