Episode 120 Reading the Signals

It is a difficult time in maternity care in the UK, last week saw the release of the report into East Kent Maternity services 'Reading the signals' which has lessons for us all.
Join me as I digest and think about this report and the previous reports of  maternity services failing families and think a little about where we go from here.

Want to know more?
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1111992/reading-the-signals-maternity-and-neonatal-services-in-east-kent_the-report-of-the-independent-investigation_print-ready.pdf

https://www.gov.uk/government/publications/final-report-of-the-ockenden-review

Thank you all for listening, if you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider. Do explore my back catalogue of episodes and feel free to get in touch to suggest topics, I love to hear your thoughts and ideas. If you have found my ideas helpful please recommend theobspod to others who may be interested in exploring all things pregnancy and birth. You can find out more about me on Twitter @FWmaternity & @TheObsPod as well as Instagram @TheObsPod and email me on TheObsPod@gmail.com please check out #MatExp matexp.org.uk for ideas about how to improve maternity experience.
  My beautiful artwork is thank to Anna Geyer www.newpossibilities.co.uk

Thank you all for listening,  My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider.
If you have found my ideas helpful whilst expecting your baby or working in maternity care please spread the word & help theobspod reach other parents or staff who may be interested in exploring all things pregnancy and birth.
Keeping my podcast running  without ads or sponsorship is important to me. I want to keep it free and accessible to all but it costs me a small amount each month to maintain and keep the episodes live, if you wish to contribute anything to  support theobspod please head over to my buy me a coffee page  https://bmc.link/theobspodV any donation very gratefully received however small.
Its easy to explore my back catalogue of episodes, I have a wide range of topics that may help you make decisions for yourself and your baby during pregnancy as well as some more reflective episodes on life as a doctor.
If you want to get in touch to suggest topics, I love to hear your thoughts and ideas. You can find out more about me on Instagram @TheObsPod and email me on TheObsPod@gmail.com Please also check out #MatExp matexp.org.uk for ideas about how to improve maternity experience.
My bea...

Transcript

Copy Transcript Copied

Florence 0:00

Hello, my name's Florence. Welcome to the Obspod. I'm an NHS obstetrician hoping to share some thoughts and experiences about my working life. Perhaps you enjoy Call the Midwife, maybe birth fascinates you, or you're simply curious about what exactly an obstetrician is. You might be pregnant and preparing for birth. Perhaps you work in maternity and want to know what makes your obstetric colleagues tick, or you want some fresh ideas and inspiration. Whichever of these is the case, and for that matter anyone else that's interested, the Obspod is for you. And you may have been surprised. It wasn't that I didn't think that this was an important topic. I did. But I'm in the situation where I actually know Donna, Donna Okenden. I worked with her closely at the London Clinical Network, and we agreed that she would come on the podcast. I'm sure you realise that despite her best efforts to want to come on the podcast and my desire to talk to her about her report and her review, things have intervened in the meantime. She's a phenomenally busy woman. And therefore, although we had a date in the diary, it hasn't happened, and in the meantime, she's taken on the Nottingham Maternity Review as well. But I feel with the publication of Reading the Signals, an independent investigation into East Kent, it's time for me to touch on the maternity scandals, the numerous maternity investigations that are ongoing in the UK at the moment. It's not an easy topic, as you can imagine. It's very emotional, but I feel it's starting to be the elephant in the room. I need to do an episode, I need to acknowledge it. So today I'm going to share my thoughts. When Morkham Bay, the Kirkcutt report, was published back in 2015, part of me thought there but for the grace of God go I. Not that I was working in a dysfunctional unit, I wasn't. But I could see how one event might lead to another event, and that confirmation bias and thinking that you're doing the right thing could actually take you further and further away from your aspirations. I was shocked. I have read Joshua's story, and I'm in no way saying that anywhere I've worked has had similar issues. But I could see how a chain of events might lead to a unit becoming like that. But at the time it was very much a tension between is this a one-off event in a one-off place with particular issues and concerns, or is this a more general problem? And I found it difficult to talk because everything quickly became focused on normality in inverted commas and normality or vaginal birth being pursued at the expense of anything else. The idea of an ideology about birth. We are animals, we are designed to give birth, and we're lucky enough to have modern medicine that in some situations can be beneficial over and above what might happen naturally. Part of our role as doctors and midwives is to try and work out when things are diverting, starting to move away from what our bodies and our babies are designed to do into territory where things are becoming more complicated and therefore more likely to go wrong. But it's very difficult to have any kind of conversation about this in the climate of the time where it felt very much like an argument was raging between intervention and not. At the time the National Maternity Review was taking place, and when it was published, it had amazing aspirations. But I can't help that feeling its implementation has been hampered. Maternity transformation boards were set up, it felt like another layer of bureaucracy and assurance being introduced. Although we were talking safe and personalized care, which is absolutely what we need to do, the five-year maternity transformation program quickly got subsumed in the ten year NHS long-term plan. And in my view, maternity once again sank to the bottom of the heap, diluted, less priority. There was lots of discussion and conversation about listening to voices, listening to women, and maternity voice partnerships certainly have thrived, not just because of this stance by NHS England, I'm under no illusion, it's mainly been due to the determination of many women that set up national maternity voices and influenced and got maternity voice partnerships into such documents as CQC inspections, CNST, Clinical Negligence Scheme for Trusts, and other quality standards. But alongside that, I was involved in presentation at Expo NHS, MatX the musical. We wanted to showcase the use of maternity voices, co-production in all its glory, up and down the country being used for change. Co-production is messy. You may hear what you don't want to. And Matx the musical whilst demonstrating really powerfully how maternity units up and down the country were innovating and co-producing things, it was nearly squashed by the powers that be as not being suitable to be on the main stage. And rather than being celebrated as an amazing vision of what co-production and really listening to families looks like, it was discarded, forgotten, as if they were embarrassed. We had snippets of video we'd taken ourselves, but the official video we were promised never saw the light of day. If we're serious about listening to families and listening to patients in other areas of healthcare, then this needs to come from the top, not just clinicians and managers at local level, but entirely through the system. This was an opportunity for a demonstration of what could look like how really listening to women and families and parents could benefit services and drive improvement. And it was an opportunity totally missed. And makes me wonder if the reports about listening to patients is actually lip service, a nice to-do rather than seen as the core, the fundamental foundation of everything. Then came the pandemic, and it's been difficult to look at maternity transformation through the pandemic because the pandemic brought so many of its own challenges in the way we work. And then we've never really recovered from that. We're in a situation at the moment with the publication of the Ochinden reports, two of them, where there are immediate and essential actions that every maternity service needs to take at a time when we're facing the most unprecedented pressure I have ever seen in my time as a consultant. I've never seen staffing this low. We're facing a national shortage of midwives. And at the conference I attended recently, we're told we're short of around 2,000 midwives and 500 obstetricians. It feels like we're firefighting every day. It's exhausting, and I'm seeing it take a toll on even the most compassionate staff that I work with. CQC ratings for maternity services seem to be at an all-time low, with six percent services being inadequate and forty-seven percent of services requiring improvement. This is worrying. And whilst we need to accept and reflect and improve on these results, I also ask myself whether this is some attempt by the CQC to correct past issues where services were rated as good at a time when actually inquiries have found later that they were far from good. We all have stakes in the game, the regulators included. So where do we go from here? And what about the report itself? I found reading the signals a really interesting report. No, maybe I can't say that. I found the recommendations interesting. I found the report shocking really shocking. Some of the descriptions of the way families were treated, their concerns dismissed, turned away, spoken to in an atrocious way. And then the comments between the different staff groups, I found the whole thing utterly outrageous, and my disgust at how this could have happened in this country in my profession, it's profound. But the recommendations were interesting because they try to be more systemic. They acknowledged some of the difficulties that maternity services are facing, and that these can't be isolated issues, and that idea of how if you don't knit problems in the bud in a unit, you could end up down the rabbit hole, kind of digging yourself deeper and deeper and getting in a mess. Much like Ochenden, reading the signals divides into four key components in terms of actions. The first is monitoring safe performance, finding signals among the noise. I've done a recent episode on the fantastic report maternity data, so what? We're drowning in data. There's so much data, but meaningful data, and how that tells us we are or aren't safe, and how that tells us we're doing in the context of our population, our case mix complexity is less easy. And the idea that if we had better, clearer data, a small amount of valid maternity and near natal outcome data that would help us identify which units, which places are outliers, and then provide help and support to those units, then that would be fantastic. The second recommendation standards of clinical behaviour, technical care is not enough. Well, I don't know where to begin with this. It's obvious kindness, caring, compassion. Listening to women and their concerns, listening to concerns of families. I've said before on this podcast it's so basic. But they've gone a bit deeper into this and recommended that this needs to be a key part of the curriculum. And I agree this is something that at the moment the curriculum has improved on, but still could beef up considerably. How we embed compassionate care into practice at every level, medical student, postgraduate education, and then continuing professional development for consultants. But then the second point in this is about how to sanction professionals who are not compliant with the correct levels of behaviour. Well, you'd think we would already have these things in place. We have the GMC, after all, so the General Medical Council, and the NMC, the Nursing and Midwifery Council. But I can tell you, having been both a consultant and in management for a considerable amount of time, that to actually manage to discipline and have any effect on a consultant or a nurse or a midwife is nearly impossible. I've seen it done probably less than a handful of times in my entire career, and in each case, it's been done only down to the sheer grit and determination of a particular manager or matron who has really stuck at it, stood up for the fact that it needs to be done, and has done it in the face of adversity and sometimes in the lack of support from others within the organisation or from HR. It's very difficult. And it's difficult for me to talk about, even and acknowledge that this is a problem because I've seen it happen so few times that if I discuss any details, it'll almost certainly be immediately identifiable. I've had situations in which I have been concerned, and when I've raised it, I've been knocked back. I've even had it turned on me that it's my fault I'm discriminating or not valuing an individual, I am not treating them fairly. So it's really challenging, this one, and we need to own it and acknowledge just how difficult it really is. The report talks about a cycle of negative behaviors. Standards start to slip when clinicians are exposed to bad behavior of senior colleagues, and then this bad behavior becomes normalized. Behavior that would otherwise be challenged becomes tolerated, unprofessional behavior, lack of compassion, and failure to listen becomes accepted and embedded. The report covers a period from 2009 to 2020. And this makes me think because standards of behavior in terms of being kind and compassionate and listening, well, those have always been there. But some of the standards of behavior about what we expect from a group of consultants have radically shifted in that time. And it makes me think about the fact that with many things in healthcare, if you're not advancing forwards, then it isn't that you're steady stating, you're actually slipping further and further behind. In 2009, in my own hospital, the standard was for consultants to be present on the labor ward from nine in the morning till five in the evening, Monday to Friday. Yes, of course, we were actually there much more than that. Or at least some of us were. But that was what our contract was. That was what we'd committed to do. But in 2010, we introduced 98 hour cover. The idea that a consultant would be present on our labour ward from eight in the morning till half past ten at night. This is a very different set of standards and behaviours. And to me, when I look back twelve years later, well obviously we're on the labour ward. Obviously we're present. Obviously we're there to be involved hands on in cases clinically. But equally I know that not all units have moved forward. And so I can see something that was acceptable in two thousand nine, if you haven't advanced it, it's now wholly unacceptable. The world has significantly moved on in that time. The next action that the report talks about is teamwork. The importance of effective teamwork it describes flawed teamworking pulling in different directions, teams lacking common purpose, struggling with competing interests, descending into conflict with inappropriate hierarchies and power plays, a struggle for ownership of maternity care. The problem with teamwork is it can become a self-fulfilling prophecy. Units that have a good culture and good teamwork tend to attract staff that work in that way. And they become stronger as a result. One of the things about my unit is there's always been an excellent relationship between midwives and obstetricians, which I know can be problematic in other maternity units. We have a really good culture of talking to one another, doing work properly jointly, collaboratively. It's always been like that, and therefore when we appoint people, we appoint with that in mind, and then they come and work in that sort of environment. If you have a unit where teamwork isn't good, good people may join the organization and attempt to change it. But attempting to change culture from within can be lonely and difficult. I know I am not alone in knowing colleagues who have been bullied and undermined in units where they've worked, and they've tried their best to improve care, speak out, stand up for women, stand up for other members of staff. And in some cases this has been successful, but in the majority of cases I've seen those compassionate, caring, value-driven, well-meaning individuals gradually demolished and often leave because the task is too much, the task is insurmountable, it's too difficult, there's too much adversity, there's not enough, there's not a core nucleus of people that want the change, who are ready to get on board and move things forward. And in the East Kent report, I definitely see that replayed. People coming in and trying to change the culture, trying to change the behaviour, and being unsuccessful and then either leaving or being replaced because they haven't been successful. Long ago, I was lucky enough to be on a maternity leadership programme run in London, and I had the privilege of listening to Professor Michael West talk about teamwork and the idea of pseudo-teams. We think we're a team, but actually we haven't come together. We haven't agreed a common purpose, we haven't then reflected on where we're at in the task part of the way through, and then we're all doing different things, and this is a pseudo-team, and that pseudo teams actually don't work well and can be detrimental to healthcare. If you want to read more, there's loads of talks of his online. So there's a recommendation about Royal College really looking at how teamwork in maternity and neonatal care can be improved, and how the training and employment of junior doctors as well as small senior clinicians can really improve effective teamwork with proper common purpose and objectives. And whilst I applaud that as an aspiration, I'm slightly struggling to know how. The report talks about teams who train together, working better together. And many of us do joint team training in obstetric emergencies, but it's bigger than that, and I'm not totally sure how we tackle that, despite the fact that it's clearly an essential element. The final action area is organizational behaviour, looking good while doing badly, and this is something I recognise. It may sound totally nuts. How would you not know if you were doing badly? There are so many ways of measuring and assessing how you're doing that you can have some results that suggest you're good or even outstanding, and other results that suggest you're not. The pressure internally when your service is seen as good or outstanding, and possibly or one of the jewels in the crown of an organization, it can be very difficult when you start to say, Hey, you know what? I'm not that sure we're that good. And again, this isn't something I've experienced hugely, but it is something I've experienced small amounts of. One has to be careful what one says at external events. Perhaps this is a legacy of foundation trust status and the idea introduced of the NHS as a competitive market. If you're competing, as it were, for business, I don't agree with that. But is it any wonder that organizations want to make themselves seem good and attractive and want to try and keep their dirty laundry to themselves and fix it internally? There have certainly been situations in my career when I've undertaken reviews and I've been challenged. Florence, you're being unrealistic, you're setting too high standards, and that has been difficult to reconcile with being honest and transparent. Yes, perhaps I can be too harsh, but isn't that okay? Shouldn't we always strive to be doing our complete utmost? And whilst all these events are in the past, and I wouldn't want women coming to my organization now thinking these are current issues, there are things again that I can see could have a slippery slope. There definitely is a vested interest in organizational reputation when you're faced with local reorganizations, possible mergers, and possible closures of units. It's inevitable. And so, whilst it's distressing, sadly, I'm not surprised at this finding in the report. Right, I've given you some rambly thoughts. What's my zesty bit? I think my zesty bit for professionals is we have to own our problems. We have to accept our flaws. We can't be perfect, whether that is at an organizational level or whether that is at a national level, as a group, a profession. We cannot undo what has been done, but we can take responsibility for it, and we can take responsibility for improving it. And I am hopeful about the future because I know that there are many very caring, very compassionate obstetricians and midwives that I meet, for example, at the recent conference I went to, that I exchange emails with, or discuss things with on social media. There are a lot of good people who want to make maternity care better. And as I said to a colleague recently, we shouldn't get too despondent. Let's hope that this is rock bottom, and therefore the only way is up. We are going to get better, we are going to improve, we are going to learn from this. But what we have a collective responsibility to do is to try and rebuild trust. Trust in maternity services, trust in maternity care, and trust that when something does go wrong, if it does, which it inevitably will some of the time, trust that we will be open and honest with our explanations, our investigations, and our apologies. And whilst I can't undertake the systemic change that reading the signals calls for, I can role model to the best of my ability kindness, care, compassion, good communication, and amplifying women's voices wherever I can. I understand if you're pregnant listening to this, you're having a baby, you may feel concerned. It may be difficult to read the endless stories of terrible maternity care in the press. I don't want you to feel frightened. As I've said, there are many of us providing good care in a compassionate and kind way. But for the moment, while we rebuild, I can't say completely trust us. But I can say don't be frightened to ask questions. Try and ask for information to back up decisions you're being asked to make or recommendations and advice you're being given. And if you're not immediately happy with whatever nurse, midwife, or doctor is saying to you, or the way they're behaving to you, then please do try and call it out. And if you can't call it out at that time because it's just too much and you're feeling too vulnerable, please do call it out later on, whether that's through PAL's, the patient advice liaison service, or through your maternity voice partnership, or with free text on the friends and family survey that maternity units should be asking you to complete, because that will help us learn. That will help us eradicate some of these behaviors that we should be so ashamed have happened. I very much hope you found this episode of the Obspod interesting. If you have, it'd be fantastic if you could subscribe, rate and review on whatever platform you find your podcasts, as well as recommending the Obspod to anyone you think might find it interesting. There's also tons of episodes to explore in my back catalogue from clinical topics, my career and journey as an obstetrician, and life in the NHS more generally. I'd like to assure women I care for that I take confidentiality very seriously and take great care not to use any patient-identifiable information unless I have expressly asked the permission of the person involved on that rare occasion when it's been absolutely necessary. If you found this episode interesting and want to explore the subject a little more deeply, don't forget to take a look at the programme notes where I've attached some links. If you want to get in touch to suggest topics for future episodes, you can find me at the Obspod on Twitter and Instagram, and you can email me the Obspod at gmail.com. Thank you for listening.