Shared learning database

Blackpool Teaching Hospitals NHS Foundation Trust
Published date:
August 2013

Organisational change focusing on normalising birth at Blackpool Teaching Hospitals NHS Foundation Trust has led to enhanced quality of care and satisfaction for patients and staff.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

Implement organisational change to support women to make appropriate choices for their delivery following a previous Caesarean section:
- Ensure high quality of care for women giving birth
- Improve patient experience by normalising child birth
- Safe appropriate level of Caesarean sections

Reasons for implementing your project

In 2006/7 Caesarean section rate in Blackpool was the highest in the North West, at 28%. There was a very medical model for maternity care in place. Now, as a result of sweeping changes in the organisational culture and a focus on normalising births, the current rate in 2013 is 24%. Realising that the answers to our problems lay with our staff, we changed the management culture releasing the potential of staff to make changes. The organisational changes were supported by the Trust Board who were keen to see an improvement in Caesarean section rates, both from a patient experience perspective and also from the perspective of quality of care and cost.

This work supports national policy described in the National Service Framework (Department of Health 2004), Maternity Matters (Department of Health 2007) and NICE clinical guideline on Antenatal Care (2008), NICE clinical guideline on Intrapartum Care (2007) and NICE clinical guideline on Caesarean section (November 2011) guidelines. National policy includes offering choice to women as to where they give birth including home birth, increasing the percentage of women having a vaginal birth, increasing the use of non pharmacological pain relief, in particular the use of water in labour, a reduction in the percentage of women whose birth was induced medically and an improvement in patient experience.

How did you implement the project

Work to reduce the Caesarean section rate was supported by the NHS Institute. Improved training included normal birth study days, education about VBAC (vaginal birth after caesarean) and improved training on intrapartum fetal monitoring. The hospital also set up VBAC clinics (see key learning points section below for more detail).

Blackpool has worked to normalise the birth environment, replacing beds with couches and beanbags. Baths were added to en-suite rooms for pain relief in labour. Although a more staff intensive approach, staffing levels were increased to meet National standards and enable midwives to offer more one-to-one care in labour and the normal birth study days have provided the midwives with evidence based theory and practical skills to effectively normalise birth and manage long latent phase.

A key change has been the introduction of the patient safety tool, SBAR. Midwives and obstetricians write information relevant to each patient in the delivery suite. It provides a structured system for communicating, particularly amongst multi-disciplinary teams and gives more junior staff a vehicle for making themselves heard in a way that everyone will listen to. Initially, it was greeted with some shock and scepticism. Within 12 hours everyone was on board and no-one wanted to go back to the previous system. The SBAR board gives us an easy way of identifying which women are likely to require intervention or reviewing and who is high and low risk. The scheme has now been extended to handover between shifts and between wards and to other parts of the hospital as it provides a consistent way of communicating which everyone understands.

Another intervention has been the development of the Incident review meeting which supports the culture of openness and communication. Facilitated by the Clinical Governance Lead the open meeting provides an opportunity to review incidents for the benefit of the whole team. Meetings begin with a discussion of further actions from the previous week. Minutes from the meeting are disseminated horizontally to staff on the wards and vertically, to the divisional and clinical meetings.

Key findings

Local patient satisfaction surveys have demonstrated improved patient experience compared to the Healthcare Commission review of maternity services in 2007. The local surveys demonstrated a significant improvement in how women rated their satisfaction of their maternity care.

During this process the service has reported continuing improvements in staff satisfaction surveys. Staff have reported in a positive supportive environment.

A 4% reduction in the Caesarean section rate provides improved patient care and safety along with large financial savings, as the cost of a normal delivery is cheaper compared to the cost of a caesarean section. A reduction in the length of stay following birth has enabled the maternity service to manage the increasing birth rate with no adverse effects to women and their families.

Having achieved a reduction in Caesarean Section rates and an increase in successful VBACs (up from 50% to 65%), there is a palpable sense of pride. Staff confidence, particularly more junior staff has increased. Staff use the same approach to care regarding the history, women expectations and plan of care for each woman. The promotion of normal birth is not regimented but we make clearly-documented decisions. The midwives are buzzing from the changes and there has been a rise in job satisfaction. We have moved from a culture of anxiety to one which is proactive in encouraging VBACs, but that also accepts that intervention is necessary in some instances.

A two-way appraisal system is another illustration of cultural change. The system enables junior members of staff to comment on the performance of senior staff, and vice versa. It proves beneficial in identifying improvements that individuals can make, tackling problems before they develop, improving the sense of teamwork. Training, too, is delivered in an open and accessible way. Dates are posted on notice boards and anyone linked to maternity can attend, from healthcare assistants through to paramedics. People are put into multi-disciplinary teams and asked to re-enact emergencies.

Key learning points

The hospital set up VBAC clinics for all women who have had one or two Caesarean sections to support women in their decision making and explain that previous Caesarean does not mean another Caesarean. Community midwives were able to directly refer women early on in their pregnancy to a midwife led clinic where concerns and options could be explored in a 45 minute appointment. A detailed proforma outlining the risks and benefits of VBAC was completed and a management plan for delivery was agreed. This clinic was supported by an Obstetrician for guidance on suitability for VBAC. At the incident review meetings the atmosphere is relaxed and informal - anyone can contribute - although the subject matter is taken seriously. It is a format that works well, previously there had been a culture of mistrust and incident reports were looked at in isolation, taking a long time for information to be fed back to staff. By looking at incidents whilst still fresh in people's minds, a no-blame culture develops; people are willing to speak out about what happened. That way, we can all learn from each other. The process of sharing the minutes from these meetings horizontally and vertically has become possible as a result of cultural change and this supports the trust's philosophy that no one department can change the culture of an organisation.

Links have been made with other North West maternity units to share our learning and good practice. Within our own maternity service regular staff training is held including 'Normal Birth Workshops'.

Although Blackpool has successfully enhanced the quality of patient care by improving patient satisfaction and having a more appropriate Caesarean Section rate using organisational change, this innovation is on going as the trust does not want to stand still and the potential to improve the normal birth rate and improve patient experience continues.

Contact details

Dr June Davies and Nicola Parry
Consultant Obstetrician and Gynaecologist and Head of Midwifery
Blackpool Teaching Hospitals NHS Foundation Trust

Primary care
Is the example industry-sponsored in any way?