Continuity of carer and local delivery of care: implementation framework

Introduction

The Best Start Five-Year Forward Plan for Maternity and Neonatal Care in Scotland (2017) was the result of a Strategic Review of Maternity and Neonatal Services in Scotland. The Review group was tasked with making recommendations for a Scottish model of care that would contribute to the Scottish Government's overall aim of delivering person-centred, safe and effective care.

The Best Start aligns with the National Clinical Strategy for Scotland (2016) and sits within the context of Realistic Medicine (2014‑15) requiring transformational change to redesign services with a focus on local care, built around families and communities and the key concept of continuity of carer. Reflecting Scotland's asset-based approach to promoting the wellbeing of families and children through the Getting it Right for Every Child (GIRFEC) model, the Best Start recognises that maternity and neonatal care services matter to the health and wellbeing of Scotland's people. The health, development, social, and economic consequences of childbirth and the early weeks of life are profound, and the evidence shows that this is felt by individual families and communities, as well as across the whole of society.

• All mothers and babies are offered a truly family-centred, safe and compassionate approach to their care, recognising their own unique circumstances and preferences.
• Fathers, partners and other family members are actively encouraged and supported to become an integral part of all aspects of maternal and newborn care.
• Women experience real continuity of care and carer, across the whole maternity journey, with vulnerable families being offered any additional tailored support they may require.
• Services are redesigned using the best available evidence, to ensure optimal outcomes and sustainability, and maximise the opportunity to support normal birth processes and avoid unnecessary interventions.
• Staff are empathetic, skilled and well supported to deliver high quality, safe services, every time.
• Multi-professional team working is the norm within an open and honest team culture, with everyone's contribution being equally valued.

Continuity of carer

Continuity of carer will see women building strong relationships with their midwife and receiving care tailored to their individual needs and circumstances. Evidence shows that outcomes for both mothers and babies are improved when they receive continuity of midwifery carer.

The vision is that:

• Maternity and neonatal care will be co-designed with women and families from the outset, with information and evidence provided to allow each woman to make informed decisions in partnership with her family, her midwife and the wider care team as required;
• All women will have continuity of carer, regardless of their individual circumstances or risk status;
• Midwives will deliver the full continuum of care and provide continuity of carer; with the majority of midwives working in a continuity of carer model, regardless of their base;
• Women who need the input of an obstetrician will have continuity of a primary obstetrician throughout their antenatal and postnatal care;
• Separation of mothers and babies will be minimised through the development of neonatal transitional care and neonatal community outreach;
• Boards will offer the full range of choice of place of birth which includes homebirth, Alongside Midwifery Unit/Freestanding Midwifery Unit (AMU/ FMU) and obstetric unit, appreciating that geographical considerations will restrict some Boards, such as island Boards;
• High performing, multi-professional teams in place in every Board.

The new Nursing and Midwifery Council Future Midwife Standards outline proficiencies and educational preparation for midwifery going forward and have a key focus on continuity of carer. Domain two of these standards focuses on safe and effective midwifery care promoting and providing continuity of care and carer. Therefore all newly qualified midwives will be prepared to work in this way.

This document provides maternity services with practical guidance for implementation of continuity of carer and local delivery of care, neonatal transitional care and community hubs, and summarises policy expectations. The document is the output from the Continuity of Carer and Local Delivery of Care Sub group of the Best Start Implementation Programme Board, informed by learning from the five Early Adopter Boards (EAB) – (NHS Forth Valley, NHS Highland, NHS Lanarkshire, NHS Lothian and the Clyde area of NHS Greater Glasgow and Clyde), Royal College of Midwives (RCM) listening events and stocktake visits by the Best Start Executive Team. The document describes not only the structural but also the cultural shift required in order to effect change. It reflects the experience of those midwives providing care in the new model and also the experience of those leading the change.

In reflecting the findings from the five EABs, it is important to note that they were chosen to reflect the diversity of Scottish NHS Boards in terms of population, geography and demographics, therefore all started from a different baseline.