{"id":40634,"date":"2017-11-14T18:31:07","date_gmt":"2017-11-14T17:31:07","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=40634"},"modified":"2017-11-28T13:19:41","modified_gmt":"2017-11-28T12:19:41","slug":"florence-wilcock-sometimes-we-need-to-break-the-rules-to-improve-healthcare","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2017\/11\/14\/florence-wilcock-sometimes-we-need-to-break-the-rules-to-improve-healthcare\/","title":{"rendered":"Florence Wilcock: Sometimes we need to &#8220;break the rules&#8221; to improve healthcare"},"content":{"rendered":"<p class=\"standfirst\">To truly understand and improve outcomes, we will need to be brave<\/p>\n<p><!--more--><img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-37499 \" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2016\/09\/florence_wilcock.png\" alt=\"florence_wilcock\" width=\"129\" height=\"152\" \/><span style=\"font-weight: 400\">The publication last week of the <a href=\"https:\/\/www.rcog.org.uk\/en\/news\/national-maternity-and-perinatal-audit\/\">National Maternity and Perinatal Audit (NMPA)<\/a><\/span><span style=\"font-weight: 400\">\u00a0<\/span><span style=\"font-weight: 400\">shows that there is significant variation in practice and outcomes across maternity services in Britain. The provision of this baseline level of data should in theory allow us to monitor the improvements that are being made through the <a href=\"https:\/\/www.england.nhs.uk\/mat-transformation\/\">Maternity Transformation Programme<\/a> and the <a href=\"https:\/\/improvement.nhs.uk\/resources\/maternal-and-neonatal-safety-collaborative\/\">Maternal and Neonatal Health Safety Collaborative<\/a>. Yet to truly understand and reduce variation we will need to be brave. We will need to take a critical look at ourselves and our practice and understand the human factors that make us slow to change. <\/span><\/p>\n<p><span style=\"font-weight: 400\">Healthcare is on a continuous journey of change. Change over time is partly due to new medical evidence\u2014although translation from evidence to clinical practice is not straightforward. Studies show that there is an average\u00a0time lag of <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC3241518\/\">17 years<\/a><\/span><span style=\"font-weight: 400\">. <\/span><span style=\"font-weight: 400\">Change is in part limited by professionals\u2019 understanding of new evidence, habit, and unconscious bias; patients also bring their own perspectives and expectations. <\/span><\/p>\n<p><span style=\"font-weight: 400\">Individual courage and initiative are needed if we are to make change in complex systems, which tend to preserve the status quo. A key example mentioned in the report is the wide regional variation in the rate of skin to skin contact in the first hour of birth, despite there being longstanding evidence of the benefits of this for both mother and baby. Even as far back as 2004,<a href=\"https:\/\/www.nice.org.uk\/guidance\/cg132\/chapter\/1-Guidance#care-of-the-baby-born-by-cs\"> NICE guidance<\/a><\/span><span style=\"font-weight: 400\">\u00a0<\/span><span style=\"font-weight: 400\">recommended that healthcare professionals should facilitate early skin to skin contact between newborn babies and mothers at caesarean births.<\/span><\/p>\n<p><span style=\"font-weight: 400\"><img loading=\"lazy\" decoding=\"async\" class=\" wp-image-40635 alignright\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2017\/11\/skintoskin_whiteboard.jpg\" alt=\"\" width=\"324\" height=\"204\" \/>An inspirational midwife I know, Jenny Clarke <a href=\"https:\/\/twitter.com\/JennytheM\">@JennytheM<\/a>, became so frustrated at the lack of skin to skin contact in the operating theatre in which she worked that she climbed a ladder and wrote on the wall \u201cIs the baby skin to skin?\u201d<\/span><\/p>\n<p><span style=\"font-weight: 400\">Breaking the \u201crules\u201d (what is accepted) and exposing yourself to the possibility of negative fallout is a personal risk. Yet the ultimate result here was a permanent whiteboard in the theatre asking the question \u201cis the baby skin to skin?\u201d and a change in behaviour, so that skin to skin became the norm at Jenny\u2019s hospital, benefiting many mothers and babies.<\/span><\/p>\n<p><span style=\"font-weight: 400\">The impact of Jenny\u2019s actions reaches beyond her own trust. She continues to campaign for skin to skin contact by volunteering to speak at events, writing blogs, rapping, and spreading ideas via social media. Talking with Jenny about her work encouraged me to change my own practice. I also started to question and break \u201crules\u201d little by little. <\/span><\/p>\n<p><span style=\"font-weight: 400\">I started with skin to skin contact at caesarean section births, then new guidance was issued on the benefits of delayed umbilical cord clamping so I started that too. Then I started to question why I handed the baby to a midwife to take to the mother after caesarean sections, so I started passing the baby straight to the mother for skin to skin contact as soon as\u00a0it was born\u2014just as we would for a vaginal birth. As I pushed these small boundaries, subsequent improvements we could make began to unfold too. If the baby is skin to skin with its mother and we are delaying clamping the umbilical cord, then the next logical step was that the birth partner could cut the cord as this procedure was no longer in the sterile surgical field.<\/span><\/p>\n<p><span style=\"font-weight: 400\">As I change practice, I also hope that I am acting as a role model for others to do the same. I know that we are currently a long way from achieving 100% skin to skin contact\u00a0in the first hour. The NMPA recommends that \u201cClinicians should make every possible effort for all babies to have skin to skin contact with their mothers within one hour of birth, where the condition of mother and baby allows. For babies who are to be admitted to a neonatal unit, all efforts should be made to offer skin to skin contact prior to transfer of the baby where the baby\u2019s clinical condition allows.\u201d I really hope that this statement and the report make us reexamine our practice. Hopefully, we\u2019ll then be brave enough, as Jenny was, to depart from our routine habits and take steps forward that will transform maternity care for the better. <\/span><\/p>\n<p><em><strong>Florence Wilcock<\/strong> is a consultant obstetrician at Kingston Hospital with an interest in intrapartum care and improving maternity experience. She is chair of the London Maternity Strategic Clinical Network user experience subgroup and co-founder of #MatExp, a grassroots movement aimed at improving maternity experience for families and the staff who care for them. She can be found on Twitter <a href=\"https:\/\/twitter.com\/FWmaternitykhft\">@FWmaternitykhft<\/a><\/em><\/p>\n<p><strong>Competing interests:<\/strong> I have read and understood BMJ policy on declaration of interests and declare the following interests:<br \/>\n\u2022 Employed by Kingston Hospital NHS Foundation Trust, associated with London Maternity Strategic Clinical Network, current project funded by NHS England Challenge Fund.<br \/>\n\u2022 Founder of MatExp\u2014a change platform\u2014with Gill Phillips of Nutshell Communications Ltd with whom I work closely.<br \/>\n\u2022 I receive no financial benefit from any of the above apart from my employer.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>To truly understand and improve outcomes, we will need to be brave [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmj\/2017\/11\/14\/florence-wilcock-sometimes-we-need-to-break-the-rules-to-improve-healthcare\/\">More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":40635,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[236],"tags":[],"class_list":["post-40634","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-nhs"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Florence Wilcock: Sometimes we need to &quot;break the rules&quot; 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