Birthrate Plus is working on guidance to make implementing continuity of carer easier. Marie Washbrook, who has been involved with the organisation for nearly three decades, explains more.
It can be quite daunting for HoMs to think about implementing continuity-of-carer models, especially when also faced with budget cuts. Some can think: where do I start?’ says Marie Washbrook of Birthrate Plus.
England’s national maternity review, Better births, set out a vision of how maternity services should be delivered to meet the changing needs of mothers and babies, including continuity of carer. For some, it has been a challenging prospect.
‘The knee-jerk reaction is that it will take more staff, but there’s no evidence of that at the moment,’ says Marie. ‘If you move into a low-risk continuity model, it has far less impact on needing more staff so, for some units, that may well be achievable within the current workforce – if the workforce is right to start with.’
For other services – those already successful in implementing a continuity-of-carer model – the challenge is scaling it up: ‘You might have 600 women out of 4000 births in the model but can you double it and scale it to 1200 women?’
In recognition of the challenges to many maternity services, the Maternity Transformation Programme (MTP), which is facilitating the implementation of Better births, has asked Birthrate Plus to assess the impact of continuity of carer on safe staffing and provide guidance on implementing a continuity-of-carer model. Marie, who is heading the project, says it will not be prescriptive, because that is not how Birthrate Plus works.
‘It will be a framework to help units work it through when they are thinking about implementation of a continuity-of-carer model.
There will always be a local factor and demographics that are unique to a service; about 90% of maternity services are the same, but that 10% of variation needs to be scoped and covered in the methodology because then there’s more confidence in the staffing levels they provide,’ she says.
The starting point to it all is establishing a baseline so that current staffing needs are clear. Only then can a service move forward.
New guidance
Birthrate Plus was the natural choice to put together guidance. It is the successor to Birthrate, an initiative that for many is synonymous with Marie’s name and that of her colleague and co-author Jean A Ball. Marie began working on Birthrate in 1988 (see panel, right). Last year, Birthrate Plus was endorsed by NICE, which recognised the workforce planning methodology and the intrapartum acuity system.
Marie hopes the first draft will be completed by the end of the year, before further work takes place to apply the Birthrate Plus methodology in units. This further work will model the staffing required to safely deliver continuity of carer across the maternity pathway for low-risk births and all risk births. Modelling will be utilising service and workforce data from early implementers of continuity of carer, as well as those who have recently completed a Birthrate Plus workforce assessment.
Marie says that data from around 18 Birthrate Plus assessments completed earlier this year can be used. This is in addition to new work, such as two units in Hereford and Worcester, and MTP Early Adopters. One Early Adopter taking part is Surrey Heartlands: its sustainability and transformation partnership plans include forming a new, single community midwifery team and a shared home-birthing team for its three maternity units.
Marie also hopes to work with a unit planning to implement a continuity-of-carer model for all risk births. As well as ensuring a range of services is included, it’s important to include this type of model, given that Better births expects services to implement one for all risk births. It’s an area that makes HoMs worry because of how it might affect staffing.
‘When you start to look at continuity of care for an all-risk model, including those women who will need a hospital birth, that’s an area where people are more nervous and we need to be able to demonstrate if it will impact on staffing and how much you can go forward within existing resources. That’s a piece of work I’m particularly keen to explore.’
She plans to do this with HoMs with whom she has recently worked because previous assessments have provided the all-important baseline. It is important that continuity of carer is not seen in isolation, says Marie. Core services and skill mix play a role in the success or failure of a model.
‘If you’re short of midwives in the delivery suite or antenatal care because the midwives have all gone into the continuity model, then it won’t work. If you get core staffing right, it’s more likely that it will be successful,’ says Marie.
Risk assessment
Support staff contribution must also be considered. Marie says Birthrate Plus will enable HoMs to work out the support staff needed: ‘For skill mix, we’ve used a generic percentage split over the years, but the more that units introduce Better births and continuity models, the more we need to drill down. If you use an all-risk model then the skill mix required may differ to a low-risk model.’
Another factor is whether a unit is looking at low-risk or all risk births. Marie says that for all risk births it is very likely the midwives will provide continuity of carer for intrapartum care and, on the postnatal ward, care will be provided by the core midwives.
Marie says it is likely that the higher the number of complex cases, the harder it may be to do a continuity model. Local variation here becomes an important consideration. There is greater complexity and often variation in the low-risk category: ‘In data from more than 40 units over the past three years in England, the range in the low-risk, midwifery-led category varies significantly.’
That units differ so much is exactly why there can be no ‘one-size-fits-all’ approach to continuity of carer. It may be a daunting prospect for individuals to come up with their own blueprint, but Birthrate Plus aims to ease the pain.
Birthrate Plus: the workforce planning tool
Birthrate began as a means of assessing how many midwives were needed for a service to meet the number and type of births. It used a scoring system for intrapartum care, based on clinical indicators of the needs of women and their babies.
The score was then used to assign the woman and her baby to one of five categories of need, from normal birth, through increasing levels of intervention, to emergency CS. Midwife time was then allocated according to need and the average length of time spent in the delivery suite. The method enables a calculation to be made of the staff required to meet the workload and the quality of care required.
Birthrate Plus refined the methodology used in Birthrate and applied it to other aspects of maternity, such as antenatal and postnatal care, and caseload and team midwifery. Now it is a methodology for workplace planning and strategic decision-making across all aspects of maternity services.
All about Marie
Grandmother
Marie has two young grandchildren (aged three and five) and is involved in their care daily.
Boat lover
She volunteers as crew on a narrowboat on the Cromford Canal in the Peak District. She is either on the boat, explaining about life on narrowboats, or walking the towpath.
Green fingered
A keen gardener, Marie considered setting up a horticulture business after retiring but decided to keep gardening as a hobby. She visits public gardens as often as possible
