In the first part of my Mums-Power May updates, I wrote about the group bookings that we have begun to test in the two hospitals where we are working - UCH and NUH - and hinted that the process was not as easy as it sounds. Having been working at Newham along with my trusty colleague Pamela-the-Midwife, I thought I would capture some of our learning.
As a relative novice in the world of innovation, the 'practical implementation' phase of the project has been somewhat of an eye-opener for me: people and systems are difficult to change ('well of course!' I hear you all cry – ‘we all knew that!’), but I had not anticipated just how bitty and frustrating the whole process would be – I had hoped for giant leaps in antenatal service improvements rather than small steps, but it turns out that facilitating change involves a lot of the latter (you find your mind circling around the same small details – is it better to send an email of make a phone call? Does this survey look better in colour or black and white? To hold the meeting or not to hold the meeting? ).Whether or not you are making any giant leaps in the midst of all these minutiae is often a difficult thing to determine.
So the upshot is that, upon finding myself amidst the hustle and bustle of Newham Hospital’s Maternity Booking Clinic, simultaneously marvelling and startled by the busyness, noise and clamour (a rushing midwife here, a crying baby there), I have often felt myself yearning to be back in the safety of my office chair, with only a computer screen for company. And yet the learning that has emerged from my foray into the implementation of innovation has been rich, and the experience has frequently been positive. I want to share here some of the challenges and opportunities that have presented themselves as part of the testing phase of this project, and ultimately finish with a happy little story.
What we’re learning: The Challenges
Having now tested the intervention three times at Newham General Hospital, four key challenges seem repeatedly to emerge: -
It’s difficult to get the timings right: If one person arrives ten minutes late for their appointment, it’s not generally a big deal. But if three other people are waiting for that person to arrive because they are part of the same group booking appointment, that’s 40 minutes of waiting time. Equally, there is so much information to deliver in the group briefing session that it is difficult to limit this to 30 minutes while ensuring that it is still engaging and offers something different and better than is what is on offer in a typical group appointment
Different group compositions can create challenging issues and dynamics: From the language that women speak to their age and whether they’re first–time or experienced Mums, there are a lot of factors to consider when trying to achieve an ideal group composition. Putting women in the same group according to set criteria could be effective and enable information to be more appropriately tailored, but logistically it is very difficult, with many different administrative layers to co-ordinate effectively.
Space is an issue - hospital rooms are not the friends of innovation: while there exists a lot of literature and thinking about the potential of innovative spaces to facilitate learning, this is mainly in relation to education, whether formal or non-formal, and much less about the need for innovation in health-related environments. And yet few would argue that the learning you do about your own body and wellbeing is the most important kind. It is difficult to conduct a group booking in a tiny room that has been designed for a one-to-one consultation with a health professional. In order to facilitate the shift from a medical to a more social intervention, and ensure that a group booking can be delivered comfortably, this would, in an ideal world, need to be reflected in the design of the space.
It’s necessary to manage service users’ expectations: last, but certainly not least, is the need to manage service users’ expectations of health services. When people interact with the NHS, they are in the habit of expecting a one-to-one with a clinician - something which is fairly formal, professional and swift, delivered in a private space. People, not least pregnant women, expect to be reassured by professionals who know what they are talking about. A group briefing session creates a more open but unstable forum for discussion, dissolving the traditional ‘patient-professional’ dichotomy, and expecting service users to do more of the work. This is difficult for people to adjust to. Even where we have explained clearly to women what to expect when they arrive for a group booking, some have struggled to relax and accept this new way of working.
What we’re learning: The Opportunities
There is appetite for change: One of the things that I have been most pleasantly surprised by is the lack of resistance that we have met with as we have been trying to test the intervention. Service managers and midwives have shown an interest in what we are doing, expressed support and even volunteered to be involved. My sense is that this is not just about people recognising that things need to change, but that they are fundamentally interested in the process of innovation and excited by the idea of trying something new.
There is potential for greater service efficiency and more job satisfaction for clinicians: As one midwife put it, "I think midwives could really benefit from this intervention." The group briefing session eliminates the repetitive part of the booking appointment from the one-to-one, so that midwives are not constantly repeating themselves and are instead able to focus on women’s individual concerns and needs. At UCH in particular, where we have also been testing group bookings, this has also begun to reap dividends in terms of the time it takes to deliver the one-to-ones, with these interactions starting to become more efficient. There is thus potential to develop a more cost-effective service.
Clinicians learn from one another: While testing the group booking, I have heard several conversations between the midwives who are involved that go along the lines of this: “Oh, really, do you say that? I say this” or “Does it really only take you that long to do so and so?”, or “This is what I do when someone answers their mobile phone in the middle of an appointment – how about you?” Being involved in an intervention striving to achieve a ‘gold standard’ form of information sharing has encouraged clinicians to start to share best practice and critique one another’s methods of working.
Women are more empowered and connected: Our early evaluation findings have indicated that women feel more confident and informed after group booking appointments than in usual appointments. This suggests that, while encouraging a more ‘participatory’ dynamic is difficult, it nonetheless has a positive impact. Additionally, there is a broad consensus, particularly at Newham where we are working with a team of midwives who specialise in dealing with vulnerable women, that women could really benefit from the ability to connect with other women in early pregnancy.
A challenging beginning, a happy ending
The most recent intervention that we ran at Newham presented many of the challenges and opportunities that I have listed above: on the one hand, a hot, overcrowded room, a late arrival causing the group briefing session to overrun by 15 minutes, an awkward mix of women, including first time Mums and a woman in her fifth pregnancy, a shortage of rooms and a lack of midwives to deliver the private one-to-ones. Two teenage Mums were accompanied by their mothers, who were vocal about not wanting their daughters to have to share their thoughts and concerns in public. ‘"She doesn’t want to be here. She doesn’t want to be with all these people." They sat with their arms folded. They wouldn’t take their coats off, or speak to one another.
Suddenly though, things took a turn for the better. Out came our interactive board detailing what foods women could and couldn’t eat. "Tell me what foods on this board you can eat", Pamela said. The partner of one of the women piped up, and others began to follow suit. Suddenly, people were smiling, talking and asking questions. One of the young Mums took her coat off. When the midwife advised them that they should all go swimming because it was a good form of exercise, the two teenage Mums both screwed up their noses. ‘I’m not going swimming in public. I’ll be fat!" said one. The other chimed in with "Yeah, I’m not neither – that would be so embarrassing!" Pamela suggested that they go swimming together – "that way you’ll be fat together. You should swap numbers". So they did. These were the two teenage Mums whose mothers had originally been so defensive about them being in the group booking – now they were relaxed, exchanging numbers and home addresses. Later, when the group booking was over, the families walked out of the clinic together, making plans to meet up. "Bye Pamela, see you soon!" they said, as if to an old family friend.
It was by no means a perfect process, but it did have a happy ending. In Newham, the rate of teenage pregnancy stood at 47.2 conceptions per 1000 women in 2010 – one of the highest in the country. As Rachel Flowers, joint director of public health in Newham, commented: “Teenage pregnancy is both a cause and consequence of social exclusion, health inequalities and child poverty. We know that children of teenage mothers are generally at increased risk of poverty, low education attainment, poor housing and poor health and have lower rates of economic activity in adult life.” Two vulnerable young women who probably would not have had the confidence to attend antenatal classes left their appointment promising to risk the embarrassment of swimming in public, together; this was seen by all to be a very good outcome. There was a discernible buzz amongst the midwives who had been involved in the group booking. This was something new - not quite a giant leap, but more than a small step.
One of the participating midwives summed the experience up well: “It’s always difficult to try something new,” she said. “We’ll have to get the logistics right. But overall, yes - I think it’s a brilliant idea.”
Over the next few months we are going to be developing an ICT solution that will further enable us to change the dynamic between women and health professionals, forms of information sharing and ways to build peer support networks of women.