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How to make the most of your MLU

 

How can we support our local midwifery unit /birth centre?

Here, Mary Newburn and Richard Hallett answer some frequently asked questions.

“Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has.” Margaret Mead

This Q&A sheet is for people working in maternity services, Maternity Voices Partnership members and activists. It may be of interest to commissioners and maternity managers. If you prefer to download a copy, to print off and share, please click here

 First, here are some important general points for anyone who wants to achieve change:

1          Clarify what you want to achieve

Write down and fine tune what you want to achieve and why (your objective and the rationale for it).

You may not be able to fully articulate the objective or the rationale for some time. But it helps to write down your thoughts. Then they can be edited, added to and eventually fine-tuned into a few short, clear, active sentences that are easy to communicate.

Do not be afraid to change the way you conceptualise the issues and your aims, as you gather intelligence, research evidence and local facts.

2          Do your homework.

Find out and write down relevant background information. What is the problem? When did this start? How long has the situation being unfolding? What are the causes? Are there different views and interest groups? Some of this fact-finding and intelligence may be for public communication and some of the more sensitive information, involving named individuals perhaps, may need to be shared (carefully and as constructively as possible) with a limited number of audiences.

3          Decide who is driving the push for change

Decide who is involved in sharing the objective. Is it the Maternity Voices Partnership? Is it a community group? Is it an alliance of individuals and organisations in a campaign group? Think about how leaders will be identified and how communication will be managed. (See more in Q&As below.)

Leadership and communication are crucially important to get things done and to make it clear what is being lobbied for and/or changed, and why.  It’s good to have leaders with different backgrounds. Ideally, there will be multi-disciplinary, multi-agency support for the objective. If one objective is supported by different people for different reasons, that can be extremely powerful as a lever for change.

4          Identify who has power and influence

 It’s important to know where the power lies. Don’t waste time. Talk to the right people in the right way, with the right ‘case’. Better to take a bit longer to put the case together and then communicate it clearly and effectively than to spend time grumbling to people with limited power or no influence. Make your precious, limited time count.  

Effective campaigns often have a small group who can talk constructively and honestly with the key decision makers out of the glare of the media and publicity.   You cannot have an effective dialogue via local press headlines or 140 characters.  

The ‘public campaign’ will keep the issue(s) on the radar of local decision makers, but real progress (and possibly some compromises all round) will more likely come from small-scale constructive discussion.   If you are the group with the strong media links, then what you are able to offer to decision makers (ie: your leverage!) is the promise / agreement to create public support for whatever solution may be agreed.

Don’t forget the different interest groups (stakeholders):  

·      Commissioners

·      Trust/board managers

·      Midwifery / maternity staff

·      Local women and their partners

·      Local boards, committees and groups, e.g. Sustainability and transformation partnership (STP), Local Maternity System board, maternity clinical network, maternity voices partnership (MVP) or maternity services liaison committee (MSLC). The Health Overview and Scrutiny Committee (HOSC)

·      Informed / interested public (usually reached via conventional and social media)

Don’t treat these groups all in the same way.  Each group needs a particular approach, and communicator, who ‘speaks their language’ and understands their world, including their constraints and what motivates them. Ideally identify someone from your small group to speak with, and cultivate, each of these groups.

5          Communicate, communicate, communicate (but see note above!)

 Keep providing information little and often. A Facebook group can be very useful. Use photographs including selfies and simple images for a fun feel so that backing or following the serious objective feels enjoyable. Make sure you have a few contacts lined up to like, comment, share, and retweet. (See @WhoseShoes on Twitter for some good images, use of emoticons, games and software for ideas.) A logo or photo used repeatedly will give your issue or campaign instant recognition. Recognise each step and success, no matter how small. Thank people. Where appropriate, publicise the steps and the achievements.  Consider how much to communicate worries and concerns and how much to focus on communicating needs and positive goals. Worries and concerns may make for better news headlines, e.g. ‘Funding for Anytown Birth Centre to be cut’, but they can create further anxiety and alienate some key stakeholders. Think about all-round impact.

Frequently asked questions

 Here are some frequently asked questions, with prompts and tips on possible actions.

1                        The maternity unit has been closed. How can we get it re-opened?

Intelligence, is crucial. Try to establish why the unit has been closed. Don’t make assumptions or think you know, because of what people around you are saying. There may be different perspectives. Do ask a trusted friend with inside knowledge and do write to management and commissioners directly. (It pays to have friends on the inside.) If you already have a relationship or established structures for communication via the MSLC, maternity voices partnership, the clinical network or local maternity system, use your contacts.

There are no blue print answers, because solutions are context-specific. You need, however, to influence opinion formers and those in positions of power. So you will need to ‘make the case’ or put up a good argument. If you work for the NHS, or are a service user chairing an MVP, you may need to write a business case (see below) Some questions to answer include:

Numbers

·       How many births in the trust’s/board’s maternity service are outside the OU?

·       Is this number rising or falling?

·       Is the trust/board satisfied with this % of births outside the OU?

·       Are local maternity commissioners satisfied with this % of birth outside the OU?

·       Are there any capacity pressures on the provider trust’s/board’s OU?   Will there be a cost to providing more capacity in the OU?

·       Does the local trust/board have a plan to increase the number of births outside the OU?

·       Who advocates for maternity services on the relevant boards and how well briefed are they about midwifery units?   

Staffing

·       If staffing is an issue, what are the causes of any under-staffed, or reasons for perception of ‘over-staffing’?

·       If there are temporary staffing problem (e.g. due to sickness, holidays, part-time workers, holidays, maternity leave, retirement), can you help to make it a higher priority to resolve the problem?)

Financial pressures

·       If financial pressure is the reason for closure, then what are the savings the trust /board has made from closing the unit?   Can these be opened up to scrutiny? 

(In England, Wales and Northern Ireland you could ask a local councillor to put the question to the Health Overview and Scrutiny Committee.)

Other issues

·       Is there undermining occurring anywhere (e.g. from finance or management or a small, vocal critic or interest group)?  If so, this will need careful thought and planning. If so, can you have more influence than they do? Get your agenda to the fore: establish facts; share high quality research evidence and economic costings, include public health arguments and local information.

·       Has there been a serious incident (SI) affecting confidence? If so, a strategy may be needed to address this. Midwifery Unit Network and other organisations offer training and consultancy services to support trusts/boards in this situation.

Use your national maternity review recommendations and relevant guidance to the NHS as the policy context, when making your case. Quote high quality studies and reviews of evidence such as NICE guidance and Cochrane reviews. Use commissioning guidance, professional quality standards and RCM documents, such as:

 

Freestanding Midwifery Units: Local, quality care - RCM Busting the Myths. RCM (Undated).

Trends in Freestanding Midwife-led Units in England and Wales 2001-2013 RCM 2013.

 

2          Bookings are low and falling. How can we reverse the trend?

Can the unit raise its profile, making its unique ‘offer’ clear? This might be done by using any or all of the following:

·      NHS trust/board website,

·      a dedicated Facebook page,

·      (regular) news from the unit, parents’ stories, staff profiles, friends of…

If you want to emphasise the social and psychological support the unit provides use stories about emotional journeys – named or anonymous – about real women and families.

Can the unit build a community of friends? You could try some of the following:

·      Invite families into the unit and enable them to feel it is ‘their space’.

·      Invite all parents drop off a birth story for staff or the public to read.

·      Provide a wall or albums for baby photos to be displayed.

·      Engage local supporters help with fundraising, such as donating or sponsoring equipment or prizes for raffles, etc.

·      Work together – invite volunteers to help with painting or planning ways for improving the environment.

·      Create on-going volunteer roles for dads as well as mums – such as breast pump currier, odd jobs and maintenance help, antenatal clinic friends, breastfeeding buddies, etc.

·      Provide facilities for visitors to make a cup of coffee, or make sure refreshments are offered.

·      Hold antenatal and postnatal groups at the unit/birth centre, or invite the birth unit friends group to meet at the unit.

·      Take photos, Tweet, Facebook and/or add details to the website.

 

3          How can we increase the number of women using the unit?

 Referrals

·      What is the size of the available “birth market” for the unit? This could be determined from (say) the annual number of birth in the catchment area, or more specifically the number of women on the local community midwifery caseloads.

·      Which midwifery caseload has the highest % of women choosing to birth at the unit?

·      How does this % compare with that for successful midwife units elsewhere?

·      What would be the birth numbers if all caseloads were at that highest %?

·      Do all the local midwifery caseload teams support the MU to the same degree?

Use of the building

·      What is the unit used for?  

·      Is it used mainly for births or is it a local ‘community hub’ providing antenatal and postnatal care, care for local women with complex clinical or social needs /all women?

·      Could child health and women’s health and wellbeing services be co-located?

·      If not used as a maternity or children’s centre/community hub, how could this be addressed?

Multi-disciplinary team

·      Do local GPs and health visitors understand the service and support the local midwife unit, or could that be part of the problem?

·      If not known to be actively supported by all health professionals, how could this be addressed

4          I’ve been told I need a business case. How do I write one?

A business case is not about business, nor primarily about money (!), but because it will propose the use or direction of resources, cost will undoubtedly have to be considered.

In essence a business case explains the reasoning for a project, and is needed (usually) in written form to gain support from interested parties or stakeholders.  Whenever resources such as money, people’s time, equipment or facilities are ‘consumed’ they should be in support of a specific objective.    It would be better called a “project justification”, but rather than just claiming that “in these circumstances X is a good thing to do” it should include the ‘business bit’ about cost-effective use of scarce resources and measures of success.  Hints…

·      ‘Start simple’ on one side of A4 if possible…….you can always add details later.

·      State the problem or challenge you are addressing, as succinctly as possible.

·      Identify solutions to the ‘challenge’ (there may be more than one option available).

·      Even an option you don’t support could be considered to show ‘why not’.

·      Offer some evaluation of the options in terms of how successful they might be.

·      Try to assess the cost of each option (staff time, equipment, facilities, publicity, etc).

·      Ask any functional managers who could help with their bit of knowledge / expertise.

·      Try to identify the benefits of each option

-       what immediate objective does this help? (eg: increase MU births)

-       what overall objective might this help?

                              (eg: keep maternity care as close to home as possible).

·      Try to explain how this is a good use , or the best use, of relevant resources.

·      Try to explain how this supports the NHS Trust’s/board’s ‘top level’ objectives

·                                                      (eg: relieve capacity pressures on OU).

·      Include multi-disciplinary input as much as you can, and service users’ voices.

·      Identify any downsides of the project not going ahead.

·      Identify some achievable milestones / way-points and some measures of success.

·      Include any examples of good practice or success from elsewhere that you can find.

·      Test-run your business case with critical friends before you submit or present it.  You can always ask MUNet. There may be an adviser who would take a look.

·      Lobby informally for support before you ‘go live’ to help get understanding and acceptance. Knowing what is coming can often pave the way.

·      Don’t worry if you can’t do all of the above…. just include as many as you can.

·      And keep it succinct and punchy….. a paragraph rather than a page on each.

 

5          How can we get organised locally?


If you want to change something, get together with another person or gather together a group of like-minded people. If you are already connected into networks and interest groups, you have the makings of an interest group, lobbying group or pressure group.

It is good to have community groups and maternity units are stronger if they have a group of past services users who become friends of the unit.

Maternity services that have a multi-disciplinary partnership with service users at the centre, an MSLC or maternity voices partnership, are a resource to be supported and used.

You may want to set up a small action group or a sub-committee form an existing maternity committee to take forward an issue. (You could have a formal group embedded in the health system and a community action group that is more grass-roots and more independent.  Make sure there is communication between the two groups for maximum impact.)

Share out tasks, and keep reporting back to each other. Actions may include finding out…

· …the numbers of births in units, history of increase/decrease in bookings/births (see Q&As above).

· …do you have an active MSLC and or other service user involvement structures and/or individual service user activists you can work with? 

· …Is there likely to be local support from local newspapers, other local interest groups and charities?

If there’s an NCT branch, Positive Birth Group, AIMs contact, Breastfeeding Network, or doula nearby, contact them and ask to meet for a chat. Support is more likely to grow from mutual friendship than a request for a volunteer!

Set up a Facebook or other social media page, and decide on a hashtag (such as #Anytownbirths to use when you tweet, to help build your interest group. Tweet pictures and positive messages, and/or make regular Facebook posts. 

5          How can we gather local opinions and get local people involved?

If you want to achieve some kind of change, or make people aware of a positive community asset (or a risk to it), you need to engage people’s attention. Chats at the school gates and local ‘walking and talking’ activities, such as ‘Walking the patch’ where you talk to people using local services, can work well. To do this inside NHS premises you will need permission and may need a criminal records (DBS) check.

You can use social media. Join well established national social media groups, such as Midwifery Unit Network, MatExp (#matexp on Twitter) and/or The Positive Birth Movement, to generate interest, as well as local interest groups, such as an NCT branch Facebook group. Take note of the aims and etiquette for each group.

 

An online survey with a mix of ‘closed’ and ‘open’ questions can help you to find out what local people think and what they care about. SurveyMonkey offers a free service for a basic survey of fewer than 100 people. Ask midwives, health visitors and community organisations to pass on the details.

If you hold a public event, local press, radio or TV may be interested. An online petition can sometimes be helpful, but you need lots of contacts to drive enough people to the website.

Written by Mary Newburn and Richard Hallett