Don’t give up on me, baby (aka how to halve avoidable injury)

Imagine having a normal pregnancy, only to have a difficult birth ending in a damaged baby. Imagine the damage was preventable, if only the obstetric care had been better. Your baby would not recover, and neither would you or your family.

Each such case should be a scandal. Yet many women and their babies across the UK still suffer preventable harm. Over half the costs of NHS legal claims are associated with childbirth, and the personal and societal costs don’t bear thinking about.

Guidelines on safe care exist – many follow them, but some don’t. Given the dangers around childbirth, why ever not?

Training, checklists, protocols – yes, all needed. But the key ingredient is better team working – behaviour and communication.

Tim Draycott, a consultant obstetrician at Southmead Hospital, developed a team-based programme using evidence from a large randomised study. Introduced at Southmead Hospital in 2000, the result was a 50% reduction in babies born starved of oxygen and a 70% reduction in babies born with a paralysed arm. He says ‘If training were as effective nationally as it is at Southmead Hospital, over 100 severe birth injuries would be prevented each year, which would significantly benefit children and their families, and could also potentially reduce £64 million per year in NHS litigation claims alone’.

Tim’s team developed the same training programme into an ‘exportable package’, the PROMPT Course in a Box, which could be set up in other maternity units worldwide. It’s already been tested across the UK, the US, Australia, Botswana, and is now being rolled out across Scotland.

As an Improvement Science Fellow at the Health Foundation, Tim has gone onto research what barriers can stop team learning and the spread of good practice. Make the right thing to do the easiest, he says.

But spread is often difficult, even with obviously useful interventions. Why?

It is because intervention + context = outcome. So often we focus on the intervention – the thing, the new technology, the kit, the service – the animate thing. But the soil in which these seeds grow and spread is more inanimate – the context, the behavioural, the cultural – are the kinds of things that most busy professionals (and evaluators) run a mile from facing. Turn away from this and efforts fail, progress is not possible and funds wasted.

In our recent publication Perspectives on context, seasoned experts dissect the issues in four essays. There are broadly two aspects of context: factors external to a provider that affect behaviour within it; and factors within.

On external factors, some of these relate to the policy cocktail or ‘ecosystem’ in which providers operate. Sitting in a meeting at No 10 recently – in which some trying to make integrated care work locally eyeballed politicians, arm’s length body chiefs and senior officials – was instructive. The locals listed key policies which were blocking progress and suggested some that could enable, and the nationals agreed to help.

Dr Tim Ferris is a General Internist at Massachusetts General and lead of Partners HealthCare in Boston, an Accountable Care Organization. He told us recently about changes to national rules on the way hospitals under accountable care programmes in the US are paid for Medicare. He says that these changes are having a potent impact on the activities by clinicians. So, national policies can be context busting locally.

Within providers, our experts have carefully identified the main factors affecting context, drawing on literature from the past 20 years. It’s a great read. The main message is tend to each factor as appropriate to the intervention, rather than ignore them. At the centre is of course the value of leaders, who can intuitively or with help use practical wisdom to steer a course through the context thicket. Remembering that many service interventions adapt and change as they are developed, such leaders have to scan rapidly that dynamic environment to make the most of it.

But underneath it all, remember those babies. If that isn’t a motivator, what is?

Jennifer is Chief Executive of the Health Foundation, www.twitter.com/JenniferTHF