Sarah-Jane Marsh: Implementing the National Maternity Review - key updates and progress so far

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Sarah-Jane Marsh, Chief Executive, Birmingham Children’s Hospital and Birmingham Women’s Hospital, and Chair, Maternity Transformation Programme Board, shares her thoughts on turning the vision set out by the National Maternity Review into reality.

This presentation was recorded at our conference, Shaping the future of maternity care, on 3 November 2016.

Transcript

Good morning everybody. My name is Sarah-Jane Marsh.  I’m the very, very proud Chief Executive of Birmingham Children’s Hospital, where I have been the Chief Exec now for seven years.  And Birmingham Women’s Hospital, where I’ve been the Chief Executive for just over a year.  But very soon, hopefully, we will be Birmingham Women’s and Children’s Hospital creating the first women’s and children’s hospital in the NHS which we are thrilled about.  We are hoping to be able to go live at the beginning of next year and think there are huge and massive advantages because we know that the link between excellent maternity care, the best start to life and fantastic outcomes for children are very, very much connected.  So, passionate about that role.

But I’m now equally passionate about being the Chair of the NHS England maternity transformation board. It was something that was asked of me, actually whilst I was on maternity leave.  I had my second child, my little boy Ronnie, in October and I was asked between the Christmas and New Year if it was something I’d think about.  Well, I had my little eight week old, thinking crikey, I can’t even manage to get dressed by 10 o’clock, let alone chair a maternity transformation board.  But, I sort of warmed up to it, bit by bit and started in April and it is the most fantastic and fulfilling role.  However, it is hugely, hugely challenging.  So, yes, I have been in post since April and it is a huge challenge because what Julia has essentially done, is hand me the most amazing report, that whilst she authored, I know many people in this room, have been involved with people throughout NHS organisations.  Most importantly of all, women and families.  They have said what they want and now Julia has given it to me to say, thank you.   Now it’s your job to go on and deliver it.  And that’s why my presentation is really about how we are going to take that vision and together make it a reality.

So, what’s driving us to do better. I think, quite simply, we know we are not getting it right at the moment.  We know we get it right sometimes.  We know a lot of interventions and things that work but we don’t do them universally and it’s leading to these, kind of results.  So, we know we are not giving women the meaningful choices that they want, either antenatally or in terms of their choice of where they have their baby.  We also know, that what we are ticking on our forms about choice is not necessarily what a woman’s experience is.  And, therefore, we are not having some of the right conversations and not having the conversations in the right way.  We know we are not providing all of the emotional and mental health support that we need to, that one in five women do not recall being asked about any emotional or mental health problems at the time of booking, which we know is absolutely crucial if we are going to get them the right care.  We still have an issue with stillbirths.  We have got a huge ambition to tackle it and we have done very well over last years.  But it’s still a huge issue.  And I guess, the one at the bottom, is becoming increasingly alive to me, because at the end of last week, we had a bit of a confirm and challenge session with Simon Stevens on what we had done in our first six months.  And he homed straight down on this smoking rate one.  So, I feel a lot more familiar, perhaps, with it than I was seven days ago.  But his challenge, there actually was, we know it’s something that we absolutely need to tackle.  We know that the adverse outcomes it can have for women and babies.  Yet in some parts of the country, the rate is as high as 25 % and in some other parts of the country it’s 5 % and whilst there is some obvious correlation with socio-economic deprivation, it isn’t entirely obvious.  So, why is it that in some places, we can get this right and in some places, we cannot?

So, we know we have got a whole series of things that we need to do better. That’s what led us to the vision that’s set out in ‘Better Births’       which Julia has talked through all of the key components of that.  I won’t take you through them again, just in the interests of time, as I have got enough to talk about.

We are obviously now, very focused on not only making sure that this is really meaningful and understandable to health care professionals and they understand what we are trying to do, but also that we continue to keep women and families very much involved. And making sure that, as part of this process, they can absolutely point to things that are different for them.  And these are just some of the things that we want women and families to be saying about maternity care that they’ve experienced in years to come.

So, here we are into the meat of it. We are sitting in the centre of this diagram, as the maternity transformation board which I chair.  We have been in existence since April and we’ve had three meetings.  I think it’s fair to say, we are in a start-up phase.  So, the first couple of those meetings are really making sure we’ve got the structures and the processes and everything else right that we need to and we report up to NHS England, the five year forward view, the Chief Executive’s board and we certainly have the interest of NHS England.  Whilst it may not have seemed like it in a run up, to have two hours of Simon Stevens’s time last week, to actually go through what we’ve done about the hard elements of implementation only six months in, just demonstrates how interested NHS England are in making sure this absolutely happens.

So, reporting to the programme board, there are nine work streams. And one of the things that I would ask you to note about them, is that they are led by very senior people from right across the health system.  It’s not just NHS England or NHS improvement.  We are involving all the national bodies.  We have got Health Education England leading, we’ve got Public Health England leading and we’ve also got one of our works streams led by the Department of Health.  So, this is everybody coming together from commissioners, providers, education commissioners, public health, coming together to play their part in delivery of the vision.  And we’ve done a lot of work, which I wouldn’t show you, because you would still be here at midnight, which demonstrates that if each of the work streams deliver what they need to do, we will have met the twenty-eight recommendations that are set out in ‘Better Births.’  So we have been very, very meticulous.  One of the things that was handed over to me by Julia and Cyril, who was Julia’s deputy, these are all completely integral.  We can’t just now pick 20 that we would quite like to do.  We absolutely have to take all 28 of them and embed them.  And embed them, we have.

There’s a very strong sense of accountability here. So, while we are all very nice people that are very passionate about maternity services, there’s a very hard edge here as well.  So, we are very risk focused.  If things aren’t happening at the pace that they need to, be very clear about what action needs to be taken.  So, this is something that we are taking very, very seriously.

We have an excellent working relationship with the stakeholder council, which Julia chairs, and then also sits on the board. That’s fantastic because we’ve got a whole group of experts we can go to if we need to ask any advice or to come on and help us with one of the work streams.  And they can also be a bit of a sort of professional nagging device, if we are to go astray.  And nagged I am, sometimes, and that’s fantastic because that just shows how passionately everybody is now tracking the implementation.  But, there’s very much two sides to this and I guess that’s what I would want to focus the rest of what I’m going to say this morning, on.

I absolutely know, there are things that we need to do nationally via the transformation board, that unless we do, and do them well and do them quickly and do them thoroughly, we are not going to be able to do this implementation. However, if we did all of these things beautifully and nothing happened locally, then we wouldn’t actually have changed very much at all and I really believe there are things that everybody, right across the NHS, can be getting on with now to play their true part in this transformation.

So, some of the things that we are doing nationally are the things that we can only do. So, the pricing and the payment reform, for example, we’ve heard a lot of people say it’s really very difficult to move money round the system, to get the payment into the right parts.  To reward the right things, the right behaviours.  We can’t have every single local organisation doing their own pricing so that is something that we are working on nationally.  We’ve also got to have common data sets and indicators.  We can’t have people measuring things about quality in a different way.  So, we are doing that.  Obviously working with Health Education England around commissioning of work force placement etc.  Again, that needs to be done nationally.  But there are lots of things that can be done locally and if you take nothing else at all from what I say this morning, please take this term of ‘local maternity system’ with you.  The local maternity system is the way that we are going to be making changes now, in line with the implementation of ‘Better Births.’  As Julia said, our local maternity systems by and large, although if I have my way very shortly perfectly, will be mapping onto the sustainability and transformation footprints.  So, we will be having 44 local maternity systems across England who need to work together to do this delivery.  It is not okay, however, great and dynamic and individual obstetric unit might be, or however dynamic a group of community midwives might be, to now go ahead and develop one part of the system in isolation.  That is not what women told us they wanted.  They don’t just want one bit of it to be great.  They want it to be great from the minute they first make contact with services, to the time that they are ready to go off into health visitor and other resources.  And, I’ll come in a minute, to tell you a little bit about what I believe everybody in this room, could do now about their local maternity system.

Also, some of the issues, for example, around continuity of care. Yes, it is a national work stream.  Yes, we need to be working with Cathy from the Royal College, to think about how we can develop this, but actually in my local area in Birmingham we have just got all the midwives together from our local maternity system and said ‘How can we do continuity of carer here?’  We are not waiting to see what the Royal College says, we are not waiting to see what I say, great.  We are not waiting to see what the transformation board says because really the answer to the question lies in the expertise of the midwives that we’ve got in our organisation.  So, we don’t really need to wait for anybody.  And the rules are – there ain’t no rules at this point in time.  We don’t really know how to do it, so it’s almost like, if the first teams come up with the answer, we’d be delighted for you to tell us and then we can come out and see you, to see how you’ve done it and share that practice.  So, lots and lots of things that can be happening locally and hopefully what we’re doing nationally enables and supports that, but it certainly doesn’t do it.  We’re also working with two sets of people.  I’ll talk to you first about our choice and personalisation pioneers to see how some of the concepts and ideas in ‘Better Birth’ actually working in reality.  So, one of the big things that was heralded at the time the report was published, the personalised budget, is something that we believe, is a massive enabler to choice.  But the reality is we don’t know for a hundred per cent whether it is going to work or not.  So, rather than say, yes let’s implement it everywhere across the country, we are testing it out with seven choice and personalisation pioneers, which you can see, they’re positioned a good spread around the country on the map.  They’re all doing it slightly differently, so, some of the areas it’s a complete universal approach where everybody, as part of that area, will be piloting the budget.  In other areas, it’s more targeted for women with specific needs or specific groupings, where we think there might be a huge benefit from that.

Very excitingly, we have actually exceeded your expectations, Julia, because they’re going live from now, not from Christmas. So, it is probably one of our works dreams that has accelerated faster than any other and all seven areas of the country are about to go live and indeed, I think, it is just this week in some of those that have been a bit quicker off the mark.  And we will be evaluating and sharing that information as we go.

We are also in the process of selecting a small number of earlier doctors and hopefully there will be people in this room, who have applied for earlier doctor status and you will have come for your interviews last week. We have been madly doing the evaluation and reading all the material and getting very excited and we desperately hoped that we could have the information on the slide but we are not quite there.  We are hoping we will be there in the next couple of weeks.  But the idea of the earlier doctors, is that we test the entire implementation of ‘Better Births’ now, in a local area to see what actually works.  And in the earlier doctor process, we have been really, really careful to pick different areas of the country with different challenges that are, perhaps, different levels of maturity.  If we just take everybody that’s doing it really, really well now, we are not going to get all the learning because we have got a whole variety of models out there.  The things in the circles, though, are the areas that we’ve really asked the earlier doctors to focus on.  So, the big themes set out in ‘Better Births.’  We want to know what they’re going to be doing about personalised care planning, continuity of carer, improving postnatal care, electronic records, payment and I think a couple of our earlier doctors will test out new payment methods and a single point of access across the local maternity systems, which again came through in the some of the bids.

So, if you haven’t heard anything yet, that’s neither a good nor a bad thing. We will be in touch as soon as we possibly can.  But more importantly, I guess, than just the specifics of that, we’ll be out there sharing the information and making sure that the learning that comes from those earlier doctors can be spread far and wide.  However, again that seemed all a bit up there and what I really wanted to focus on, in the last part, are the things that I feel that every single person can now do to make a contribution to delivery.

So, individually we have all got to engage with the maternity agenda. I think I’m speaking to the converted here but I do, do some presentations still, including presentations to groups of midwives, where people have not heard of the report.  I am sorry but it’s true.  So, I think we’re almost there but we’ve got a very small tail, that haven’t quite got there.  So, please do everything you can personally to engage.  Re-read ‘Better Births’ it is a very, very readable document and start to think through for yourself what you can do to play your role in the implementation of it.  Champion it in your teams and some of the essence of it, and we have had the discussion in the board, that yes we have got nine work streams but the majority of what women told us and continue to tell us, is actually to do with culturing communication rather than some fancy pants IT system or whatever else it might be, that we are implementing.  Women just want to be listened to, they want to feel safe, they want to have appropriate language, they want to have options, they want to feel in control.  Almost all of that is to do with the relationship that develops between the woman and the health care professional.  We are an organisation of people and relationships and I don’t think we should miss that, as we go down into the detail of the work streams.

In your own teams, the learning culture, that isn’t something that is going to come nationally, that’s about meeting together, as teams reviewing data, looking at outcomes, making sure that is part of every team meeting. What has gone well this week, what hasn’t gone well?  What should we be looking at in more detail?  Ask people at the end of a ward round, or at the end of a clinic or a session, what’s the best thing that happened today?  What’s the thing that we would like to do better next time?  There is £40,000 available to every single organisation to carry out some multi-disciplinary training this year.  It is not a competitive bidding process. The money is there for every single organisation.  You can access it via the Health Education, England website.  You do have to pick from a menu of training packages.  You can’t be completely bespoke but the menu is vast.  So, there’s lots of things and again it is about encouraging you to choose the thing that is meaningful to you.  You might have done some of this stuff before.  Other bits of it might be new to you.

There is also an innovation fund that has been launched. This is looking for innovative ways, particularly around patient experience.  That is a bidding process but again I would encourage, that’s via the Department of Health, I would encourage people to bid for that.  I was asked to plug it because, as of yesterday, we hadn’t actually had too many bids in.  So, if you feel that you have got something that you’d want to put forward and it is a really innovative way of improving patient experience, please do get that in, you have got every chance of being successful.

In your own organisation, do everything you possibly can to engage with leadership teams, with the board. I do think the door is opening for maternity services.  Often, in general hospitals I know we are left to just get on with it, because we tend to sort of, consume our own smoke and do a good job and we haven’t got 80 trolley waits in our emergency department.  We are not part of that and therefore perhaps we’re not quite as high on the profile of the board, as we could be.  The door is opening for us, but we have to push it hard.  We can’t always wait for people to come to us and be interested, we’ve got to take our passion, our enthusiasm.  So, does the Chief Ex in your organisation know anything about ‘Better Births?’  Do they know what it is that they can do to support you to make it happen?  If they don’t, go and knock on the door and push it hard and take every opportunity to really promote that and that equally for the local maternity system.  In the first STP submissions that we have read, there is a massive, massive variation in what people have said about maternity services.  From a small number of the 44 who have a very extensive route and branch plan for how they plan to implement ‘Better Births’ through to around half that haven’t even got the word ‘maternity’ in them when you do a word search.  So, there is a massive variety of levels of development here.  Now, we will make a move on this, clearly and it is part of our job nationally and I often get challenged on this.  What can you do to get my STP leadership to wake up to the fact that maternity is really important because they seem to have forgotten.  And we’re going to be doing some of that.  We are just developing at the moment, some tools by how we might do that.  And get the really simple messages for people who are never going to read it out there.  So, they absolutely understand what it means and we can hold people to account.  But, I think everybody has got a job to do, to do that lobbying as well.  So, could you not, in your organisations write  to your STP lead, explain to them why this is so important.  Tell them what you can do to solve the problems if somebody would just empower you to go ahead and do it.  Make your voice heard.  Make sure that those leaders know how important this is.  Do that lobbying and if nothing else, could you not set up your own local maternity systems in the area that you work, almost in spite of this initially.  So, could you not get together with the other units in your patch.  Get the midwives together, whatever grouping you are from and just actually say, yes we are going to create our own NMS from the bottom up.  At some point, we’ll get recognised because we’ll be helping you nationally and you’ll have obviously been writing and doing everything else, so you will be very high on the radar but you could do some of these things together now that you absolutely don’t need to be just waiting for somebody else to create what is, essentially, your system.

And, therefore, I will end on my, now infamous for those who have heard me speak before, storm trooper slide, which is we have to get angry about this, we can’t just sit back and think that it is somebody else. If we’re not happy, if we feel in our own organisations, in our own areas, that people aren’t listening to us, become a maternity storm trooper.  Turn up to the places that need to hear your voice, make sure everybody knows that this is the most important thing that the NHS is working on.  It is not just going to mean a better experience for women in the nine months of pregnancy and during birth and for the couple of months after, it is the only programme the NHS is working on that has got the potential to have impacts for generations to come and we have to make sure we get it up there.  I will play my role.  Julia, will play her role.  But everybody in this room, everybody in your networks, needs to play their role as well, if we are really going to get the maternity transformation that women deserve.

Thank you.

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