Maternity

Matthew Taylor

Hello and welcome to Leading Improvement in Health and Care. The new podcast from the NHS Confederation, the Q community and the Health Foundation. 

Penny Pereira

In this series, we'll be speaking to the people leading the way when it comes to improving health and care in services and systems. 

Noshin Menzies

The first barrier to get over was getting people to realise that this wasn't an issue with black women's ability to advocate for themselves, this was an issue that belonged to the NHS services providing the care and that it was systemic racism.

Matthew Taylor

We'll be shining a spotlight on improvement done well, but we also want to be open to really explore the challenges involved in improvement. 

Sonah Paton

Despite our outcomes on paper being good, there was lots of softer, more subtle experiences that we'd gone through that also needed addressing. 

Penny Pereira

We'll be exploring the way improvement can transform health and care, and how to make change last.

I'm Penny Pereira, I'm managing director of Q at the Health Foundation. 

Matthew Taylor

And I'm Matthew Taylor, CEO of the NHS Confederation. And this podcast is part of a broader ongoing collaboration between our organisations called Learning and Improving Across Systems.

Penny Pereira

Yeah, so we're working with health and care systems across the UK, boosting their ability to learn and improve collaboratively.

We're doing that through a peer learning programme and insight and innovation projects, sharing what we're learning throughout. And we're also making this podcast. Spotlighting some great examples of improvement in action.

Matthew Taylor

And Penny, the last time we spoke, we focused on patient flow in the north of England.

But this time, Penny, you've been on the road to Bristol to meet a team doing some really crucial work in maternity care. So Penny, tell us a little bit more about where you've been. 

Penny Pereira

That's right, Matthew. This time I'm going to be speaking to some of the improvement leaders at Black Maternity Matters.

They're a groundbreaking collaboration tackling the inequitable maternity outcomes faced by black mothers and their babies. They're working to support maternity systems to offer safer, equitable care for all. 

Matthew Taylor

And Penny, this couldn't be happening at a more important moment. And I think there are two really important bits of context for this.

The first is, you know, the general situation we're in, watching the racist and Islamophobic riots breaking out, you know, just completely shocked by that. Looking at the impact that had on the staff at the Confed, but I could clearly see also the impact it was having on staff all the way, across the NHS. So that just that reminder of the work of tackling over and structural racism and how important that work is. But then there's the specifics of the challenges within the health service and the stats from Black Maternity Matters from the Race and Health Observatory, which we're proud to host at the Confed, they're pretty stark. In the UK, black mothers are up to four times more likely to die during pregnancy or in the post-natal period than white women. And still birth rates for black babies are over twice those for white babies. So, this is a really, really important issue, isn't it, Penny? 

Penny Pereira

Indeed. And the work of the Race and Health Observatory in profiling and starting support action in this area is a really important development. I'll say a little bit more about their work at the end. 

What I found interesting in doing this episode is learning that the way in which we understand what's driving these outcomes needs to shift and the way in which that needs to happen. So you know, the fact of unequal outcomes for black women and their babies, that's been known for some time. But what we're going to hear from the team is that actually, we need to really understand what's behind those outcomes and the role that racism is playing. 

The work that we're going to hear about doesn't just look deeper at the challenges of unjust, unequal outcomes and help us think more clearly about the type and the scale of interventions that are needed. It goes on to show how collaboration and improvement approaches are helping enable practical change. 

These podcasts are reaching a wide audience. I'm really pleased that we're able to go deeper in this episode into the experience of black mothers and their babies to do justice to this particular and pressing challenge.

There's lots in here that I think will leave you fired up, better equipped to make progress for this group if you work in maternity services. And there's also some really useful wider lessons for how we approach change that I'll draw out at the end. 

Matthew Taylor

So let's get into hearing more about the project.

Penny Pereira

Let's, so, over in Bristol, I sat down with three people who've been central to this collaborative work with Black Maternity Matters

Sonah Paton

So my name's Sonah Payton, I'm one of the founding directors of an organisation called Black Mothers Matter and we are one of the collaborative partners on the Black Maternity Matters programme.

Noshin Menzies

Hi, I'm Noshin Menzies. I'm a senior project manager at the Health Innovation West of England and part of the Black Maternity Matters Collaborative. 

Ann Remmers

And I'm Anne Remmers. I'm maternal and neonatal clinical lead at Health Innovation West of England and I'm part of the Black Maternity Matters collaboration.

Sonah Paton

So Black Mothers Matter started as a result of myself and two other friends, also women racialised as black, all having babies at the same time. Um, one of those friends is a clinician and shared kind of links to some of the headline statistics. But as three women kind of going through that experience at that point, we realised actually the statistics and those headlines in the Embrace report were just one part of the issue or highlighted kind of one problem. And from our own experiences, despite our outcomes on paper being fine, good, there was lots of softer, more subtle experiences that we'd gone through that also needed addressing. And, you know, we talk about, yeah, near misses and those softer markers that aren't always captured in the data and research, but have huge impacts on black women, their babies and their communities.

Penny Pereira

Tell us the story of how the project kind of developed in the early stages and where you've gone from there. 

Sonah Paton

So with the work at Black Mothers Matter, like I said, myself and my friends had formed this amazing support network. And we really wanted to extend that to others. And we leapt into kind of providing resources and services to other black women giving birth that we thought would have been really helpful when we were going through it, but quite quickly we had this feedback that kept coming back that kind of turned into one of our big insights at that time that as a black woman, there's a limit to what you can do to protect yourself or to prepare yourself.

And actually this issue needed to be tackled from lots of different angles and being able to influence those responsible for the care of black women and their babies was really important too. And at that time we started conversations with Noshin as well, who was really aligned with how we'd been thinking.

Noshin Menzies

At the Health Innovation Network, one of our large pieces of work is maternal and neonatal safety. And Ann and I were really frustrated that this really apparent patient safety issue wasn't being considered a patient safety issue. It was very much a kind of background piece of information that women racialized as black and their babies were doing, you know, horrendously worse off compared to white women.

And the conversations we were having with people in the systems in the trust at the time Oh, well. It's because you know, English isn't their first language or because of deprivation. And actually a lot of the kind of first barrier to get over was getting people to realise that this wasn't an issue with black women's ability to advocate for themselves. This was an issue that belonged to NHS services providing the care and that it was systemic racism. 

And so the time that we came together with Black Mothers Matter and the our other partners, it was the right time because we were able to come together as a collaboration and put all of the parts together that we needed to get this work kind of pushed forward.

Because we very quickly realised that this wasn't about giving people the tools to understand different cultures or understand what languages people were speaking. The whole role of this was to tell people that it was their responsibility to kind of unlearn all of the kind of societal racism and structural racism that we have in the NHS.

And so it was, it was the right time for us all to come together to do that. 

Ann Remmers

I think it was about doing something different as well, because there were a lot of courses you could go on. There were weekend courses and two or three hour training on cultural diversity, which had been happening, which many of us had gone on those to learn more. But it didn't appear they were making an impact on the outcomes. 

And so we wanted to do something that was different and more in depth, took people on a journey, formed a community of people that were working together to learn together and then to carry that on. So we put together our proposal and we were very lucky that the Health Foundation said, yeah, we're going to support you with that in the bid that we put forward.

And the other key thing, and I think this came out of a conversation Noshin had with Sonah when Noshin said, what do you think of this idea? Sonah said, well, if you're going to do something like that, if you're going to do an anti-racist education programme, it needs to turn into something. 

So it needs to be when people go back to work, they have changed, they've learned, and they want to make improvement. So it actually is something that you're not just going on a programme, but you're actually being supported to make a difference. Because we felt like that's, that must be the bit that's missing. Because people are learning, but it's not turning into change.

So that really incorporated quality improvement. 

It's a six month programme, which is a bit daunting, you know, for managers of services to think about sending their staff on six month programme. So we had to do a lot of convincing around that. 

It's face-to face-session. So we have three face-to-face sessions, whole days; in between those face-to-face, we have virtual sessions, which are book clubs, action learning sets combined. So people time to reflect on their learning to read more around it. We supply recommended books for people to then discuss. We've even had authors of those books come along and join in the book clubs as well. And we also support people with quality improvement. So that could be anything from people that haven't got much experience of quality improvement or those that have got ideas and want to take them forward. 

With each cohort, we've learnt more. So, we've evaluated and we've refined some of those aspects. And I would say, particularly around the quality improvement, we've now refined it to a point where people are actually working on quality improvement programmes together.

So we cover a number of different trusts that provide maternity services, and they can communicate with each other around what they're doing and share their learning. 

Penny Pereira

And you're developing that into a bundle of different interventions? 

Noshin Menzies

We are. So we have just completed our third sort of cohort, our third run.

So there's nearly 200 people now who've been through the programme. And what we've identified is there's key themes that people kind of tend to work within with their quality improvement projects. So as Ann said, we've now organised communities of practice around those themes. But we're now working with the Race and Health Observatory to work that up into, we started off calling it a care bundle because that's the kind of thing that we're used to doing in the Health Innovation Network. But we've realised that it's more of a framework. So the idea is that it will help trusts or other NHS organisations to work together across leadership all the way down to the people who are kind of providing care to women and families to organise their anti-racist work around those key themes and the learning from the quality improvement projects.

So we're really excited about trialling that. That's starting to be tested with one of our trusts shortly. 

Penny Pereira

When you think about using improvement methods in this territory, is there anything that we need to pay particular attention to?

What does it look like to do improvement in an anti-racist way?

Noshin Menzies

That's been one of our biggest learning points. So we naively, when we started, thought, you know, you'll go through your training and then you'll come out at the other end and you'll very neatly have a project that you can go away, go back to your usual place of work and get started on.

But when you're undertaking quality improvement or transformation, I think, as we've started to call it, within the field of anti-racist practice and theory, it's a whole other ball game - because you've got a range of barriers that aren't there necessarily when you're doing typical quality improvement. For example, if you're introducing a new kind of pathway or way of working, because what you've got are the very varying positions that people are on their own anti-racist journey of understanding.

So what you are doing is you are coming back from a full day's immersion where you've gone through this transformation and you've kind of had your eyes opened and you understand now the way the world is set up and how that results in harm for black women and their babies and you're met with somebody who has not even the first clue about how to start understanding their role in kind of perpetuating racism.

So you've got a level where you need to find a way to have that common ground and understanding with people who might be resistant to it or might be interested in anti-racism but not in it as far as you are. So there's been a lot of learning around that kind of setting the scene and understanding that other people's perspectives or even internalised racism themselves and how that might play out in terms of the fertile ground for your quality improvement project. 

Penny Pereira

We're talking about the kind of collaboration that's made this work possible. There's lots of complexity to collaborating across organisations and systems anyway. When we're doing that, again, in relation to issues such as racism, are there particular dimensions or considerations that come out? 

Ann Remmers

I think one of the things was that we did actually start off calling it cultural competency or cultural… 

Noshin Menzies

…diversity, diversity… 

Ann Remmers

…fluency. And we quite quickly I think realised we needed to say what it is on the tin, you know, it is anti-racist.

And I think we were hiding a bit behind that using the word ‘racist’ because quite often people would say, well, we're not racist, we don't need to do this. But it is something that the educators take people through, particularly on that first day, so that they understand that is what it is and that's what's happening. And they may not have seen it because in their experience, they have never experienced racism themselves. 

So that's something that is a very important part, I think, of the first part of the programme. 

Sonah Paton

I think the individuals involved from each organisation have had to all be quite brave as individuals in their roles within their organisations, and I think that's something quite early on that everyone involved subscribed to, and they were ready to rise to the challenge, which helps the collaboration really move forward.

I think as well, from the beginning, despite the organisations being involved, all being quite different in terms of governance, size, objectives. We've never lost sight of that end goal and despite the different kind of power dynamics within the collaboration, everyone has a really clear and equally important role, and that’s, I think, being maintained as the project has grown and spread and gone in different directions and I think that's been really key.

Ann Remmers

And also understanding the issues that are facing organisations. When we first put it to one of the trusts that we would like to invite their staff to take part in a six month programme - I mean this was still during covid, wasn't it? [agreement from all] - and you know people were, I can't possibly send, you know, that I just can't, I haven't got the capacity.

So that's when we were sort of, we refined, we were going to have six full days. It went down to three days, we refined it. So I think the way that the collaboration worked with the systems and the organisations was having an understanding of their needs and having an understanding of the reality in which they were working.

Also understanding the governance around their own organisations, in that there were certain things that they had to provide and they had to demonstrate to other organisations like the regional and the national organisations as well. So I think we all work together by having an understanding of, you know, where we were all coming from and what was important to us.

And it was really, I think, through our relationships with the organisations that they trusted us to do this. Because one of the ICBs, the local maternity and neonatal system said yes, we'll be part of the pilot and we got two trusts in that particular area to take part in the pilot because that was the only way we were going to know. And that would have taken probably more for that organisation to put staff forward during that particular time.

Then once we'd done it once and then we could repeat it in other areas. And I think that is also borne out in in that area we're now in our fourth year of recruiting. And the recruiting is - just people want to know when they can start it. So it's built that kind of factor that people know about it.

And it's something that they want to do. 

Noshin Menzies

I think also with the collaboration. There is a real sense of we're sort of stronger than the sum of our parts. So, Sonah had previously, with Black Mothers Matter, gone to hospital trusts to say, can we do some work around this? and nothing came of it. We know that we wouldn't have been able to kind of approach the trusts without the expertise of Representation Matters and BCOCO [19:23], who are our educational leads, and Black Mothers Matter, we wouldn't have a credible project. 

So we all are very essential to this kind of way of working for us then to kind of have that credibility and get that trust from trusts, I think. 

Penny Pereira

In terms of co production, working with people with direct experience of services. Again, is there anything that we need to be particularly keeping in mind in terms of the nature of the hierarchies, the kind of the nature of the power dynamics in when you're talking about systemic racism, or anything to pay attention to in terms of kind of trauma and informed practice?

Sonah Paton

I think from the point of view of Black Mothers Matter, we are inundated weekly with teams - academic, clinical teams - wanting to access our community to find out stories, to understand a bit more about whatever issue they're looking at. But often when we get those requests, if you just take a moment to pause or to step back, those stories are already widely in circulation.

The answers are clear. These are issues of racism, not anything else, not, there's nothing with kind of black and brown bodies, and people are quite reluctant to accept that. So I think anyone who's tasked with PPI work or something like that should question their motivation for getting the public involved and see where the answers are already displaying themselves.

Noshin Menzies

If we got £100 for every researcher that, oh God…

I say to people, they're like, Oh, do you think you could introduce us to someone? And I'm like, they're not a fishbowl. They're not like just hanging around waiting for someone to come and observe this private group of joy. Trauma mining. Yeah. 

Penny Pereira

Just to connect back to how you were building support for this work in order to get it off the ground. The role of leaders to either enable or block this, I guess, is pretty significant. What would be your ideal in terms of what you'd look for from leaders in terms of creating the space and supporting this type of work?

Ann Remmers

It’s something we did think about, talk about quite a lot at the very beginning, and we decided we needed to really engage with the senior leaders in the organisation, although we were obviously going to the managers of the maternity services and had some midwifery initially, because in the pilot it was midwives and maternity support workers. 

We did make sure that the chief nursing officers were also aware of the programme as well, and we got their support and that they were part of the collaboration as well. In fact, I think we actually called it ‘sponsorship’. We got senior board level sponsorship from every organisation. 

So I think that was making sure that they were aware. Later on they became, I think, more interested, and then when we ran a senior leaders programme, that was when we started to get a lot of senior leaders and executive board members applying to do that programme.

And that has taken us into another area really of that sort of influence and what that has meant has been probably sort of the biggest thing that's happened in the last year with Black Maternity Matters. 

Noshin Menzies

I would say that the leadership can make or break how involved an organisation is going to be and how supportive.

So some of our absolute champions and supporters have been from the people that started the pilot with us, the leaders from those organisations. They have a level of courage and curiosity, and are willing to put the trust in our hands as a collaborative, that we know what we're doing, and they kind of are willing to go with us.

Whereas when you have leadership or people who are in charge of kind of making the decisions about whether we're going to work with them or not, who are reticent or who are not curious to kind of learn about their own racism-understanding journey, then that can be a real blocker to getting this work done as well as we want it to be done.

Penny Pereira

What would be your dream about how far this could spread, could kind of live and impact more widely? 

Sonah Paton

My dream would be that it's completely redundant. 

Ann Remmers

Yes. 

Sonah Paton 

Before the time, you know, my children start having children. That's the ultimate dream. And I think we can make that happen. 

Kind of, yeah, more short term, seeing this being rolled out and trialled in different places and different spaces. 

Ann Remmers

I think if I was going to take it further, if, you know, this isn't within our reach, but I would start the education in school, primary school, because a lot of what happens on the programme is the undoing or the filling in the gaps that people have in their own education, that where racism has come from, that's where we need to start.

If we could influence that as well, that would be amazing. 

Noshin Menzies

So we already, with Black Mothers Matter, we go and go to the university and talk to second year students, but we're hoping to push Black Maternity Matters as a pilot into some local universities for midwives. 

Penny Pereira

Is there anything you'd like to say about the measurement side of things, just conscious of that being quite important to improvement, but tricky in this territory, no?

Ann Remmers

I think with the evaluation today, we've been measuring the impact on the people that, the participants really, the change in their learning. So, pre-course questionnaires and post and then interviews and so on, has been very much about how that's impacted on them and what that has led them to do. So then you get some of the quality improvement from that. 

The next phase, which we really is really starting to try and look at the outcomes, both in terms of the data that we've got, but also from people's experience, women's experience. So, how has that made a difference? You know, we've got a feeling of it from comments that people have made, both in Sonah's group and also some of the midwives that took part in the first tranche,

who have said they've noticed a difference in their own organisation in how people have conversations now. 

And I think, we don't think our work is going to be anywhere near finished until we start to see a real shift in those outcomes. But that's going to take a little bit of time, but that's what we really need to focus on because I don't think we've necessarily got the data that we want to measure yet and that the recording of that data is accurate enough.

So this is actually put a real focus onto that, you know, for example, ethnicity recording, that that's not generally well recorded or accurate. So there's a lot of work to do, but it is something we absolutely are focused on. 

Noshin Menzies

And I don't think if we had set out our kind of metrics or our measurements in the beginning, they would look nothing like what they do now.

So in the beginning, we would have been looking at mortality. We would have been looking at some indicators of kind of morbidity in pre-term or in babies and mothers. But now we're thinking about things like, pain relief, referral to pre-term birth clinic, optimisation of the pre-term - all of those kind of mode of delivery, elective section, all of those things that previously we wouldn't have known or considered were indicators or places where racism can modulate outcomes.

So we're in a really strong position now to build that and start to look back over the last three or four years and see if there's been a change in the direction of travel, but as Ann said, a real limiting factor for us is that lack of accurate racial or ethnicity, kind of self-identified data collection. And also the fact that the kind of systems aren't set up to record it in the way we want, you know, black British, is not helpful to anybody and you know things like complaints, we're not recording ethnicity data, things like that. But we're in a really much stronger position now where we understand it more in order to measure it better.

Sonah Paton

And I think open to like to maybe a difference in what good looks like. So it might be that, as a result of this project, the amount of PALS escalations from black women has skyrocketed and perhaps four years ago, maybe that would be a really bad outcome, but actually having gone on this journey, perhaps that's something that's really positive.

Penny Pereira

If you'd like to know more about this work, you can check out their website, which we've linked to in the shownotes. In the last few minutes, I'm going to draw out a few wider learning points for how we approach change in other areas. The work we've heard described in this episode is the product of co-production and iteration, supported by proper evaluation over several years and informed by the wider evidence base.

In fact, the West of England and maternity services in particular are a source of what I think is internationally important research on how to scale effectively, including work that I'm proud the Health Foundation has supported. For example, I'd really recommend looking at PROMPT, an intervention improving obstetric emergency training developed at Southmead Hospital in Bristol, and PRECEPT, an intervention giving magnesium sulphate during pre-term labour.

These have now seen wide uptake. For example, preceptors spread to all maternity units in England, preventing dozens of cases of cerebral palsy, and saving millions in terms of lifetime health and social care costs. But to start with, there were challenges with replicating the results from the pilot sites, something we're often seeing in the NHS.

As in the work of Black Maternity Matters, These programmes helped us understand the limits of training alone and the importance of paying attention to the human relational aspects of an intervention and to embedding a change in each new place that it's tried. This institute at Cambridge University, supported by the Health Foundation, is enabling better healthcare through building better evidence about how to improve.

It has a lot of work, particularly on the rigor needed to deliver change in maternity services, but with lessons that apply everywhere. The link's in the shownotes. 

We need to target resources on doing the work of change properly, and that means avoiding wasting time and energy on things that are less likely to work, or discovering things that are already known.

I was really struck by Sonah's description of people approaching her group of black mothers to observe and discover things that service users and the evidence we have already show us again and again. I just wanted to give a shout out to a project that we've supported through Q that's addressing this particular form of waste more widely.

We've helped the Patient Experience Library map the evidence that already exists, making sure we do justice to what people are already telling us and target research on filling the gaps, which their mapping shows means giving more of a voice to the poorest and those with the poorest health and access to our healthcare. You can read more via the link in the shownotes. 

Finally, I wanted to highlight the work of the Race and Health Observatory in this area. They've set up a Maternal and Newborn Mortality and Morbidity Learning and Action Network, with support from the Health Foundation. Ten teams from across the NHS in England are coming together to work on clinical improvements with a specific focus on reducing racial inequalities.

They're applying practical improvement approaches to segment their population and design change packages to address four areas where the data shows there are the most significant disparities. Examples include improving clinical assessment to determine postpartum haemorrhage risk for black women and women of colour, or early testing of HbA1c for Asian women for the early detection of diabetes.

What I've learned from this, what inspires me about it is that improvement can help us break down the sometimes overwhelming challenge of inequity to help us move to action driven by the data as well as the experience of users. 

Creating opportunities for peer learning is really important to help people doing this work learn and compare as they make specific process changes and indeed come up against the wider issues of racism that we've touched on in this episode.

It's that combined with the broader institutional challenges of change that we're coming back to time and again in this series. Check out their work. Again, the link is in the shownotes. 

Matthew Taylor

Well, you know, thanks so much for that fascinating interview, Penny. That's it, sadly, for this episode. We've been focusing here on the role of health services in improving equity for service users.

In the next episode of this series, we're going to be looking at how improvement and collaboration approaches can support upstream challenges in terms of addressing health inequalities. And we're going to be hearing about some great work happening in my old home place, of London. 

Penny Pereira

I'm really looking forward to it.

And indeed, before we finish, thank you so much to the team at Black Maternity Matters for hosting us so well in Bristol and sharing your story. 

Please do make sure to subscribe wherever you get your podcasts. And if you like what you heard this week, go ahead and share this episode or get in touch with us to let us know your thoughts. 

You can find us on X at NHS confed. At the Q community and at health FDN. 

And if you'd like more information about our learning and improving across systems partnership, please email improvement at nhsconfed. org. You can also find transcripts and our show notes on our website. You'll find the link at the bottom of the podcast description.