‘Working together towards safer births’
Verita has been working with a large maternity care unit to improve women’s services, and this has coincidentally led to the trust following two recommendations made in the National Maternity Review.
The first recommendation covers personalised care that is centred on the woman, her baby and family. This care is based around their needs and decisions, where they have genuine choice and informed by unbiased information.
Whilst the term ‘personalised care plan’ is used in the Review, perhaps ‘personalised care preferences’ would be more appropriate at reflecting the proper acknowledgement and respect for expressed wishes coloured by values, beliefs and personal circumstances, whilst recognising that plans may change as a situation changes. We are working with the maternity unit to achieve this.
It is right that the importance of genuine choice informed by unbiased information is expressly recognised. The Supreme Court judgement in Montgomery makes explicit the clinicians’ duty to take reasonable care to ensure that the patient is aware of any material risks involved in the recommended treatment, and of any reasonable alternative. Materiality is determined by whether a reasonable person in the patient’s position would be likely to attach significance to the risk. The duty extends to ensuring that the patient understands the risk.
The way that risk is communicated affects the perception of risk; a 97% chance of success is more appealing than a 3% chance of harm. A 5 in 1000 risk is often perceived to be larger than 1in 200. There is a lot of evidence that the way we frame risk influences the decisions patients that make. In addition, there is a general and collective ‘statistical illiteracy’ which makes understanding of risk difficult for many of us and visual aids can maximise understanding as well as the clinician-patient relationship.
Using shared decision-making techniques has been shown to improve patient satisfaction, compliance, outcomes and cost-effectiveness, and reduce unnecessary interventions. Not only does it improve the clinician-patient relationship but it also encourages teams to consider their joint approach to patient care and involvement. We have been working with the maternity unit to improve their tools for communicating risk and making shared decisions across professional and geographical boundaries.
The second recommendation we have been working on covers multi-professional working, breaking down barriers between midwives, obstetricians and other professionals to deliver safe and personalised care for women and their babies.
In our work, we have met with groups of different professionals providing maternity care. We have heard about a culture of silo working and lack of respect between disciplines, particularly between obstetricians and midwives. Problems include how to handle disagreements between professionals, such as whether to transfer to more specialist care. Everyone has the interests of the woman and baby as their priority, but there can be polarised differences in how to secure the best care and outcome.
The National Maternity Review sets out a vision that ‘those who work together should train together… so that they understand and respect each other’s skills and perspectives.’
We have provided multi-professional training through half-day workshops addressing the legal and professional framework for consent and how to demonstrate good practice. The training covers recent case law, the status of guidelines, communicating risk and shared decision-making tools. People were able to discuss, in small, mixed groups, difficult clinical situations they had experienced and how they would apply the legal and professional principles to several practical scenarios. The sharing of personal experiences and different perspectives allows people to hear and be heard by their colleagues. This creates an opportunity to start building shared understanding and respect.
A small group representing the range of professionals providing maternity care form a working group to agree a new and collaborative approach to providing high quality, safe, patient centred care.
This approach adopts a key finding from the Morecambe Bay report, referred to in the National Maternity review; establishing the right culture needs leadership and commitment from everyone: individual health professionals and teams as well as senior management. Above all, it requires individuals to operate as part of a team across professional disciplines.