Neighbourhood Midwives – A brief history of who we are and why we have chosen to work in this way
With the end of 2017 and our first year of providing an NHS midwifery service completed it feels the right time to give some background as to why we chose to set up an independent midwifery organisation, to describe our journey to date and to share our goals for 2018 and beyond.
Who are Neighbourhood Midwives?
NM is the brainchild of a small group of midwives working independently who were keen to explore the idea of providing our relationship-based model of care within the NHS. As well as a potential solution to the lack of indemnity insurance, it was also seen as a way to increase the limited range of choices available for women and midwives in the bureaucratic and hierarchical rigidity of the wider system. We were encouraged by the 2008 Darzi review (high quality care for all NHS next stage review) which embraced the concept of social enterprise and the opportunities it provides for clinical leaders to deliver innovation to the NHS for the benefit of service users.
We met with Liam Byrne who was then a junior health minister in the 2005-2010 Labour Government who put us in touch with the Department of Health’s Social Enterprise Investment Fund (SEIF) and, after many trials and tribulations, we were eventually successful in our grant application for the purpose of setting up a community based midwifery organisation. It took us several more years and a very steep learning curve but finally, in 2012 we registered our new organisation, Neighbourhood Midwives Ltd at Companies House.
Why an employee-owned social enterprise?
A major part of our early development was thinking very carefully about what form and structure the organisation we envisioned should take. In partnership with Baxendale who have become our investors, we explored the various legal forms that a social enterprise could adopt and eventually settled on a company limited by shares because of our key desire to ensure that all of the midwives employed within NM also had genuine ownership of the organisation. NM’s Articles of Association and Constitution are written to embed and reflect these values:
Neighbourhood Midwives’ vision is for every woman to have the choice of a positive birth experience, supported by a midwife she knows and trusts.
- Neighbourhood Midwives Limited was incorporated as a company under the Companies Act in March 2012. As an employee owned social enterprise organisation, we are committed to ensuring that our midwives have a meaningful say in how it grows and develops. Everyone in the organisation is a valued partner who is offered a supportive environment which facilitates their own clinical and personal development.
- Neighbourhood Midwives’ purpose is to be a vibrant, successful business with a strong spirit of independence and a partnership culture of collaboration and mutual support. We have in place a strong, evidence-based clinical governance framework that prioritises the safety of women and their babies and our mission is to provide a self-funded and NHS-commissioned caseload midwifery service, based in the local community, wherever it is required.
At the heart of achieving our vision and mission lie six core principles:
- Neighbourhood Midwives operates at all times to the highest clinical standards as described in our clinical guidelines and policies
- We deliver truly personalised care and form lasting and deep partnerships with our clients
- Neighbourhood Midwives is strongly committed to operating as a social enterprise with an ambition to generate and share value both with our partners and the communities we serve
- As part of this we have an ambition and passion to find ways to work with the most disadvantaged in society
- We operate a dynamic and thriving employee owned culture which is truly transparent, inclusive and innovative
- We strive to limit ways we impact upon our environment and hold the ultimate goal to become carbon neutral.
Launching our private service in July 2013:
Our ultimate aim is to be a fully 100% NHS commissioned service but in order to be eligible for an NHS contract we needed to build a track record and be able to demonstrate that we could provide safe midwifery care. We are registered with the CQC (you can read our inspection report here: Neighbourhood Midwives CQC report 2017) and work in partnership with our colleagues in the NHS to ensure women in our care can access the whole pathway of care they and their babies may need.
Establishing our first NHS contract:
In 2018 we will have been providing continuity of care to women in London and the Southeast for 5 years. Continuity of carer is now one of the key recommendations in the 2016 Maternity review report (Better Births 2016) as the optimal way to provide safe, personal care to women and their families within the NHS. 9 workstreams have been created to implement all 28 of the report’s recommendations grouped around 7 themes and the Maternity Transformation Programme was set up to oversee the process over the next 5 years.
One of the workstreams is focused on expanding choice and personalisation of care and has chosen 7 pioneers across the country to drive this change through innovative projects offering personal maternity care budgets and the introduction into the system of more independent midwifery providers. Neighbourhood Midwives is part of this exciting work and was commissioned by Waltham Forest CCG in November 2016 to offer a continuity midwifery service to women having straightforward pregnancies. One year on and our pilot has been shortlisted for the ‘Policy into Practice RCM Awards 2018 and is described as a ‘trailblazer’ in an article about the recently published Standards for Continuity of carer: (Nursing Times December 2017).
But why be an Independent Provider?
To answer this question, it is first necessary to acknowledge the challenge of creating a maternity service which, if it is going to put women at the centre of their care and provide them with continuity of carer, needs to be flexible, adaptable, localised and responsive to individual needs. If we then consider the history of caseload midwifery within the NHS over the past few decades, the tension between an overly bureaucratic, hierarchical and rigid system and the conditions needed for caseload to flourish, immediately becomes apparent. For example, some midwives who worked in caseload teams set up in the wake of Changing Childbirth but which weren’t adequately supported or resourced, became burnt out and disillusioned over time as the system failed to adapt to accommodate this way of working.
That is not to say that caseload midwifery and continuity of carer doesn’t exist within the NHS, but generally such models are few and far between and are usually regarded as ‘outliers’ …. always vulnerable to closure and with regular ‘poaching’ of the midwives to plug gaps elsewhere in the system, most frequently the labour ward – a concern which was addressed in the Better Births report:
- Midwives who work in a continuity of care caseload team need their time to be ring-fenced, and not diverted to other services – the ebb and flow of the workload needs to be understood and respected. (page 39)
When CCG’s ask their local Trust to provide continuity of care services, the frequent response is ‘it’s just not possible’ and/or ‘our midwives don’t want to work in this way’, an understandable response in the context of managing a highly complex service with it’s many and varied demands. This is where small, independent providers can help by introducing other, more flexible solutions for maternity commissioners to consider and by providing midwives who want to offer this type of care with an alternative route to do so.
We passionately believe that midwives need some more options – many have left the profession, worn out by trying to provide individualised care in a system that first and foremost relies on a ‘conveyor belt’ approach to ensure safe care. Midwives and women currently have to fit themselves into the system rather than the system flexing to accommodate them. By demonstrating that continuity can be offered through a different approach we hope to change the discourse and be seen as a positive and realistic alternative which can be safely integrated into the current offer without destabilising the whole system.
Neighbourhood Midwives as a sustainable and scalable choice:
If we are to prove there is another way, a good starting point is the concept of ‘Small is Beautiful’ – EF Schumacher’s book of economics, which could be summed up as:
‘Things are best done at the smallest appropriate scale’ (The Guardian). Rather than trying to manage complex rotas involving set hours, limited time oncall and/or twelve hour shifts for large numbers of midwives, our hub and spoke model puts the decision making and ownership of their work/life balance back into the hands of the midwives themselves. Each practice of six midwives (the spoke) is a self managing unit, supported by a central team (the hub) and with access to a ‘coach’ for facilitated reflection and advice.
We are an aspiring Teal organisation (Reinventing Organisations) using similar principles to the well known Buurtzorg model in Holland. Our passion is to create a safe, supportive and nurturing environment that facilitates our midwives own choice of working practices as well as clinical and personal development.
Adopting such innovative models of care more widely is not without its challenges but there has been huge learning gained throughout the first year of our pilot, which can be used to improve and develop our service as we go into the second year.
There has been a wide range of processes and working documents produced to facilitate integrated working with other local providers. This knowledge is now being shared across the system to inform and enable others to consider whether this is something they can implement in their own areas.
As Buurtzorg has demonstrated, this model has the potential to scale and grow, one team at a time, wherever it is commissioned. Our belief is that by developing an exemplar for self-managing teams, as well as integrating new providers into the system, we can introduce positive change in a gradual and sustainable way. Our intention is that our midwifery-led initiative can deliver the continuity that women want and that midwives can be enabled and supported to provide.
If you have any questions, or would like any further information, please do get in touch, we would love to hear from you…
3rd January 2018