2. Continuity of carer

NHS England previously expected midwifery continuity of carer to be the default model of care available to all women in England (NHS England, 2021a; NHS England, 2021c), before it was paused as a requirement due to staffing shortages and safety concerns (NHS England, 2022). This model is considered to be particularly beneficial for women identified as having a high-risk pregnancy, or those more likely to experience health inequalities, who may face barriers to traditional healthcare services, as it allows for more tailored and sustained support from an ongoing team. The approach can also involve bringing together a multidisciplinary team (including midwives, enhanced support workers, health visitors, perinatal mental health, and possibly Voluntary, Community and Social Enterprise (VCSE) colleagues) to provide wraparound support.

Within the changing national policy landscape, clarity around national policy direction on continuity of carer is required, including the feasibility of how the model should be targeted at specific population groups.

Many of the trusts we spoke to recognise the value of the continuity of carer model, with some trusts sharing local evidence that continuity of carer has led to improved outcomes, particularly for women that require additional support. Through this approach, trusts have offered longer appointments and in-depth support for women with complex needs and built meaningful engagement with these groups to improve access to and uptake of services. A trust leader from the mental health sector noted that women who have dedicated mental health midwife access, and who are treated by the same people regularly, have higher engagement with the service and generally feel a lot more supported.

Trust leaders highlighted workforce, resource and financial implications associated with implementing continuity of care. Many trusts have a specific continuity of care team that is only able to support women with the highest risk of complications, despite desires to reach a larger group of women. Most trusts have introduced criteria to determine eligibility for continuity of carer, ensuring that midwives with smaller caseloads can focus on those who need the most support. For example, one trust targeted their intervention specifically at migrants in their local area and another trust has six continuity of care midwives embedded in each community team, who are reaching into a range of Core20PLUS5 groups. However, many highlighted that there are more women who would benefit that currently aren’t able to access this support given the already over-stretched midwifery workforce.

As a workaround, some trusts have prioritised continuity of carer in antenatal and postnatal care – essentially as an enhanced community care model – but not during intra-partum care. It was noted that it is particularly challenging to resource continuity of carer during labour and delivery. One trust had discussed and agreed this approach with women, via their Maternity and Neonatal Voice Partnership (MNVP).

Some trusts have introduced group antenatal care and mental health support, alongside continuity of care, to reach a broader group of women. The aim of this initiative was to build relationships between women and their care teams, improving trust, engagement and outcomes.

In another trust, some ethnic minority women expressed that they did not want to be involved in a continuity of carer model due to concerns around racial profiling. As a result, the trust leader we spoke to believes that future criteria for continuity of care teams should be implemented on a geographic basis or by index of multiple deprivation.

Call to action: Refresh the national policy on continuity of carer to support trusts with how to prioritise which women (if not all) should be able to access continuity of care, with resource available to support trusts with larger cohorts of women at high risk.