Episode 58 Merry Go Round

Sometimes in the NHS it can feel like we are going round and round in circles when we are trying to  make a change. Here I talk about some of my experiences and why staff can find it so difficult to embrace new ideas when they feel they have see it all before.
How might we share ideas and stop reinventing the wheel?

Networks
https://q.health.org.uk/blog-post/collaborating-for-success-using-evidence-for-quality-improvement/
https://fabnhsstuff.net/
matexp.org.uk

Continuity of care
https://www.evidentlycochrane.net/midwife-led-continuity-of-care/
https://www.england.nhs.uk/ltphimenu/maternity/targeted-and-enhanced-midwifery-led-continuity-of-carer/

You can find out more about me on Twitter @FWmaternity & @TheObsPod as well as Instagram @TheObsPod 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...

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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. Episode 58, Merry Go Round. I confess I'm a bit of a scaredy cat when it comes to fairground rides. I don't really enjoy the sensation of being flung around out of control. It's not really my thing. But the one ride I do really enjoy at a fairground is the old fashioned merry-go-round. You know, the one that has horses on, they go up and down, with music playing, it's a bit more sedate. Sometimes this is known as a carousel. I love the one in Brighton that I went on a few years ago. The wind coming in off the sea, the joy of riding, spinning in circles. Why am I talking about this, you might ask? Well, the thing about a merry go round is that you enjoy it. It's an experience, hopefully a pleasure, but at the end of it you come full circle. You end up exactly where you began. And that is the theme of today's episode. Coming full circle, ending at the beginning. If you work in the NHS or perhaps another large organisation, you might recognise what I'm talking about. When I started as a consultant, I was bright eyed, bushy tailed, a labour ward lead. I was brimming with enthusiasm and ideas, and the confidence that I could get things done. I could change things for the better. I could improve our maternity service for women and staff. I couldn't wait to get started. What I hadn't factored in was my colleagues. My colleagues were more skeptical. I felt they were jaded. Perhaps they didn't want change. Perhaps they weren't motivated enough or just simply didn't care. I was frustrated. Why couldn't they see how good this would be? Why weren't they more supportive? Why were they so apathetic? I would come home and talk to my husband, who at this point in his career was a management consultant. He would patiently explain to me the basics of different personality types, different things that motivate people, tips on how to influence people, how to discuss, debate, and bring about change. He used to help me prepare for the consultant meeting, something that I often dreaded because I would be leading it and trying to bring people's ideas together and affect change. We'd talk about hierarchy and the need for senior consultants to be seen to be heard, to have their views taken seriously, be taken into consideration. And how the senior consultants might feel. Maybe they would feel threatened by us newer consultants who they may have felt were challenging for dominance of the group. At the time we watched a natural history program and we saw a great analogy. The thing that caught our imagination was the older monkeys sitting in the trees throwing poo at the younger upstart challenging monkeys. So in my house we developed a little bit of a joke. My husband would say, Remember, they're just the older monkeys throwing poo. And at the moment they're throwing poo at you, the young upstart monkey. Let them do that. It'll help them feel better. Just let it play out. Be patient. As I look back now, I appreciate my naivety. I interpreted apathy as a lack of interest, rather than the fact that they'd been there, done that, bought the t-shirt. They may have simply been exhausted at pushing the boulder uphill for so long that they'd given up. Now I'm a bit older and hopefully wiser. I can see things frequently do come full circle in the NHS. I see newer colleagues coming up with initiatives and ideas that I've tried or that I have seen others try over the years. Things come around again. Sometimes it's small fry, a small project, like a pre-printed consent form or letter template. Sometimes it's a much bigger, large-scale problem. And now I find myself sitting in the same consultant meeting, piping up saying, Yeah, we tried that a few years ago. The successes were ABC. These were the things that worked well. These were the things that we really felt we'd achieved something. The problems were XYZ. These were the things we came up against. These were the issues that you might want to unpick and tackle if you're going to make it a success this time. Because actually, last time, in the end, the project failed. Or perhaps failure is a big word. Perhaps it didn't fail, but it kind of petered out. It wasn't sustained the change. It kind of faded away over time, perhaps as the people that were involved in the project left or moved on or lost interest and took up another project. Then I stop and consider. Have I now moved into becoming a blocker? Am I now a consultant, a source of negativity? Have I become the monkey throwing poo in the consultant meeting at my newer, more innovative colleagues? And I have to check myself and think, why am I saying what I'm saying? Is it because it's not what I would do? Does that mean it's not a good idea? Or actually, is it important that I impart my experience, my knowledge of what's gone before? Because if I don't, then that's a knowledge gap and they're unaware of the pitfalls that we've previously experienced with the same project. Sometimes it's really obvious why something doesn't take off. There's insufficient resources or political inertia. An example for me might be estate strategy. Where I work, I've been involved in a number of reviews of the estates and buildings. I have over the years designed a brand new maternity unit on multiple occasions. And I'm not talking complete pie in the sky here, I'm talking about business case, how we would afford it, what the footprint of the building would be, architectural designs, the works. Really in-depth work with a lot of meetings. And if you imagine in every meeting where there's a number of clinicians, that's a lot of resource. It's the estate people time, it's the architect time, it's looking at drawings, it's drawing in midwiferies, sonographers, admin, obstetricians, everybody in the room. That's an enormous amount to put into a project that never comes to fruition. I can tell you I've done this a number of times, dating back to about 2010, and here we are in 2021, and absolutely nothing has changed. We've still never built the building. And it's not because we don't want to. But actually, the capital spend needs people external to the hospital. It depends on what's happening at regional level. South West London, I've been involved in numerous iterations of what the healthcare might look like for our population, and how many hospitals do we need, and what community services do we need over the years. And again, we've gone round and round and round in circles. And then the broader question of how many hospitals do we need in London as a whole, let alone nationally. So there are many, many different things over which you, as an individual clinician, don't have influence that impact the work you're doing if you're doing a large-scale project. So then it's obvious why these things don't happen. Politics can come into this too. I was once told by somebody actually you've got a window between elections in which things can happen. And the timescale is quite short. If you're going to have a general election every four or five years, then actually that isn't long to get some significant change done. Bearing in mind also that in the NHS there's a period of perda preceding any election and election campaigning, so everything kind of grinds to a halt in terms of decision making and what we're allowed to talk about. Sometimes it's less obvious why something doesn't happen. Let's take the big one of the moment in maternity care. Continuity of care. It's the total buzzword in maternity at the moment. We know the evidence shows better outcomes for women and babies if they're cared for by a named midwife. The woman doesn't have to repeat her story again and again. The midwife gets to know her and is invested in her journey rather than being a one-off interaction. We're part the way through implementation of continuity of care as a result of the National Maternity Review 2016. Brilliant work. Absolutely brilliant. The current contract says more than 35% of women should be booked on a continuative care pathway, and 75% of contacts should be with the named midwife. Nothing wrong with that. So why do I have a problem with that? Well I do because I know that in 2009, so 12 years ago, I was sitting round a table as part of a maternity improvement project trying to implement integrated continuity of care midwifery teams. And this wasn't the first time this had been done either. At that time, when we had our stakeholder meetings with our midwifery teams, they were very sceptical. They'd tried it all before. They knew the pitfalls. We pressed on. We had the funding, and we had this maternity improvement project joint with our CCG, although at those in that time it was a PCT, primary care trust. We aimed to have 10 integrated community continuity of care teams by the end of 2010. So by the time it came round to Better Births and the National Maternity Review, we should have been ticked off. We shouldn't have had anything to do. But gradually the project unraveled. We implemented a pilot team with some success and the second team, but then gradually further teams weren't implemented, the whole project started to unravel. The idea of an integrated team is that they would provide continuity antenatally, intrapartum, so during labour, and then postnatally. But it became very difficult to implement this alongside having the core team that were in the hospital. It's hard to know your staffing if you don't know which midwives are going to be on the labour ward, which ones are going to be out in the community at any given time. So for staffing reasons it became impossible. So we switched the implementation to being that they would do the antenatal and the postnatal bit, and they would look after the women in labour if they were on the birth centre but not if they were on the main labour ward. Then gradually that bit also fell by the wayside, and so they were just doing antenatal and postnatal again, which then came back to being similar to the community midriffery model we'd had in the first place. So we went through an enormous amount of work, a lot of project work, a lot of recruitment, training, a lot of stakeholder meetings, and several years down the line, yes, we were providing really good midwifery care, but if you looked at our statistics on continuity of care, we were not achieving that despite having put a lot of time and energy into doing so. As the project unravels and isn't implemented, then this reinforces the problem. So the next time we try and make the same change, people just aren't up for it. If we ignore it, perhaps it will go away again, the way it did last time. Maybe it's just the latest fad. Maybe if we keep our heads down, we won't have to do this. After all, nothing happened last time and it all gradually went back to normal. And I see this with lots of national maternity issues. We're working on the same thing again and again. The National Maternity Review, when it was published, was launched by Baroness Cumberledge, and she quite rightly said that there was no point having a report, putting it on the shelf, having recommendations. It's all about the implementation. And this started really brightly. The National Maternity Review morphed into the Maternity Transformation Programme, a five-year programme to transform maternity services. And don't get me wrong, an enormous amount of good stuff has happened over the last five years. There was in March a Better Births Five Years On conference looking at how much change has happened as a result and how we're working towards safe and personalized care. But I think this illustrates just how long it takes to change something. Because actually, five years is nothing. So, yes, we've made a good start. Yes, we've got a lot of improvement, and a lot of really good cultural change has happened in terms of how much we value the voices of women using our services and how maternity voice partnerships and co-production with women has become really embedded as the way we should do things. But the maternity transformation program gradually became swallowed up into the NHS long-term plan, a 10-year plan of how we're going to improve the whole of the NHS. Maternity back to being a small subset within that, and yes, a very important one. The long-term plan talks a lot about the health of mothers and babies and has all the right policies and things with which to achieve that. But we've moved the goalposts again. So as we progress, we have a bit of a tendency to change the name, move the goalposts. Partly it's inertia, partly it just takes so incredibly long to make the changes. But some of it does it prevent us from measuring and checking where we've actually got to. But we're still a long way from where we want to be. If you look back, the Kirkup report into Morecambe Bay was also published in 2015. But now we have the Ochenden Interim Report, and it features many of the same things. It just goes to show changing something within the NHS, it's like turning a container ship or a juggernaut. It's really difficult. So how can we actually improve things? How can we make sure that we are not doing the same things again and again, reinventing the wheel, everyone working endlessly on the same stuff? Well, there are people trying to change that. A target is one way of doing that. In general, I hate targets, but they can actually make a difference and make stuff actually happen. For a long time I was very frustrated that maternity didn't have any targets, because there was a lot of focus in my hospital on the A and E 4R target. Now the A and E 4 hour target in some ways was excellent. If you had a significant problem and you turned up to AE, you needed to be seen and treated within four hours, and a decision made about whether you needed hospital admission. Fantastic. But it also meant if you turned up with a trivial complaint, you were also supposed to be seen within four hours, and actually that wasn't great because that meant you might be prioritized over someone with more clinical urgency. But the thing about the target was it meant a lot of the performance meetings in my trust were focused on the A and E target, the flow through the hospital because of its impact on the A and E target, the bed occupancy because of its impact on the A and E target. So everything became about the target, because the target drives change in behaviour. If you're sitting in maternity and everyone in the hospital is focused on the four-hour AE target, you're not going to get a look-in. No one's interested. There's no target to meet. So although I don't like targets, I am pleased that there are now some targets for continuity of care as well as what stage of pregnancy a woman books in for her pregnancy. Because these are targets that may make some difference to how women receive good care and to the outcomes they and their babies receive. But targets come with caution, targets come with definitions of how you count, what you can count, at what point you can count. And so you have to do you do have to take them with a little bit of a pinch of salt. But they are driving some change. They do focus the mind because it means not only do the people in maternity know what we're aiming at, what our goal is, but it also means there's support from the rest of the hospital, the management team, and the board that we need to meet these targets. We need to make sure that the maternity unit actually has sufficient resources and capacity to try and meet these aims. So, in that respect, a target can be helpful. There are other people trying to change things about reinventing the wheel. I've recently taken part in a couple of randomised coffee chats as part of the Evidence for Quality Improvement project run by Andrea Gibbons. And then in the latest randomised coffee chat, I was actually paired with Andrea herself. Her idea is that by networking people across organisations in different roles, you can share quality improvement ideas. She runs a newsletter, she runs tweet chats, and she runs these randomised coffee chats where you can get together and share ideas with other people that are interested in quality improvement. Andrea's initiative is part of the Q community, trying to bring together different people trying to improve healthcare in the UK and Ireland. Fab NHS stuff is another such initiative, trying to build case studies, swap ideas of quality improvements, things that people are doing up and down the country so that people can share best practice. And this is a really good idea because people up and down the country are working on the same things. We're working on continuity of care at Kingston, but every maternity unit in the country is also working on continuity of care. So linking and networking different organisations who are working on the same projects is really important. And what Andrea is trying to do is build informal networks of people so that they can share their quality improvement journeys. Jill Phillips, Who Shoes, who I do so much of my maternity experience work with, is a wonder at networking. She's absolutely amazing at building connections, introducing people with ideas that may work together, lending things from one area of her work to another, and also networking people up and down the country. And we've recently done a couple of workshops on Zoom on continuity of care, and we've linked various different hospitals and individuals from different hospitals so they can share ideas on what their approach is and try and test out different ideas together and learn and benefit from that experience. So networking, really, really important whether that's formal or informal. Otherwise, we can end up endlessly asking the same question, finding the same answers, but not implementing. In my own work, one of the examples was the Nobody's Patient project. We were looking at women with severe illness in pregnancy, women with mid-trimester loss, and women with babies in the neonatal unit. There was a massive overlap with the MAT Neo QI Quality Improvement Project, which started up some time after, and we thought this was fantastic and that we could use all the resources we'd developed to support that work. But that work went off a completely different tangent, even though I was involved in it from the beginning, and now has morphed into NHS improvement, and now has come full circle, so that some of the resources we developed Jill is now using with other people that are interested in improving the working relationships between maternity and neonatal care. So although we did the project in 2015-2016, five years later we're still using the same stuff, we're still exploring the same topics, we're still trying to deal with the same problems. How about the zesty bit? What are my conclusions from this ramble through quality improvement round and round in circles? I think it's how can we make things easier for ourselves? At the end of the day, a lot of us are trying to work on the same stuff. So if we could network better and share ideas, we could waste a lot less time. We wouldn't be completely reinventing things. How do we capture the expertise of those that have tried and failed in Inverticomas before us? So that we can accumulate that knowledge and experience, whether that be locally at the unit we work at, or regionally, or even nationally. If you've been at a hospital for a while, or in primary care perhaps, and you see things come full circle, try not to be negative to the new people that are trying something. But do try and share what worked and what didn't. What were the pitfalls last time? What advice could you give? What were the issues? Why was the change not sustained? Sometimes we can tie ourselves in so many knots we can't even see the wood for the trees. And I think this is true for a lot of healthcare. We're plastering over the cracks, we're adding more and more complexity, when sometimes perhaps we just need to strip everything back and think if we were designing this from scratch, how would we do it? And this is where pregnant women and families using our services can really help us by pointing out the simple things, the things that are irritating to them, the things that could just cut through some of the rubbish or bureaucracy and make things a lot easier quite quickly. So don't get ground down. Do have that desire for change and quality improvement. Try and listen to the merry go round so that hopefully your quality improvement journey doesn't end coming back full circle back to where you begun, but takes you off on a different path, on a trajectory towards proper change, sustained change, embedded change. I do hope you've enjoyed listening to this episode of The Obspod. Feel free to contact me on Twitter at FW Maternity or at the Obspod to ask me questions, give me topics for future episodes, or let me know what you think. It's absolutely fantastic when you get in touch. I really enjoy reading your comments. As usual, I've tried to include in the programme notes some extra reading about this particular topic, both for professionals working in maternity care and for pregnant women using services. I'd like to reassure you that although I'm talking about my experiences working in maternity care, I take confidentiality very seriously and do not give any personal information about any of my patients. If you've enjoyed listening, I'd love you to recommend the OBSPod to friends or colleagues. And please do leave me a review on whichever podcast directory you find my episodes. Many thanks for listening.