‘I think the nature of the sessions being conversational and not the traditional teaching sessions that NHS staff are used to in their mandatory updating, is brilliant and refreshing. Giving people the permission to be in a complex space that is challenging and opening the door to be more comfortable with the uncomfortable in a safe and non-judgemental space works well with this subject matter. ‘

This is all rare and part of the uniqueness of the sessions.

'You can see participants going on their own journey and some becoming so motivated and driven to become part of the change by the end of it.’

Executive Summary

1. There is justifiable nationwide concern about the relatively poor outcomes in maternity and neonatal care for women and babies from Black, Asian and Mixed ethnic groups and those living in the most deprived areas as identified in the MBRRACE-UK reports over several years. There is also increasing concern about poor experiences for Black, Asian and Minority Ethnic staff working in the NHS .

2. Bob Local Maternity and Neonatal System (BOB LMNS) agreed internal funding through their 2022/23 application process for an online equity and cultural competence training package, to be delivered by The Jen Group LLP . This training would be offered system wide to the maternity and neonatal workforce. It would be an initial pilot programme with process and outcome evaluation undertaken. The intention was not to replace current standard training but to enhance this further, such as skilling up the workforce to challenge and have difficult conversations.

3. This project aimed to contribute to the aims of the BOB perinatal equity strategy by collaborating with people with lived and/or professional experience of racial and/or socioeconomic inequity in maternity and neonatal services to design and deliver a pilot programme of short courses focusing on cultural competence and cultural safety. This would enhance the current standard mandatory training offer by skilling up the workforce and contributing to positive system change, strengthened leadership within maternity system and a culture of openness and trust.

4. Improved outcomes and experiences for the maternity workforce were also anticipated. The training would provide safe spaces for participants to understand the lived experience of co-workers and colleagues. Exploring difficult conversations, power imbalances and allyship would be important components of the training, using an inequalities lens.

5. The initial plan was for The Jen Group to consult with local stakeholders, then design and deliver a course. It quickly became clear that this would be an inauthentic and potentially inequitable approach so a redesign was agreed whereby a cohort of ‘partners’ would be recruited to a longer and genuine co-production and delivery process.

6. The group called themselves the ‘Maternity Equity Collaborative’ or the Collaborative, and the courses were named ‘Maternity Equity Conversations’ or Conversations, as their chosen approach was to open up a safe and supportive space for participants to explore issue of equity and inequity, rather than delivering a lecture.

7. The Collaborative agreed a set of ‘non learning outcomes,’ defined this way to emphasise the conversational rather than didactic nature of the course. These were improvements in: a. understanding of the case for maternity equity b. knowledge of the impact of inequity in maternity and neonatal services c. skills in creating and maintaining equity in maternity and neonatal services d. ability to challenge inequitable practice

8. 98 people registered and 51 people participated in Conversations. There was a good range of representation from all the BOB component areas as well as Frimley, and there was uptake from a range of junior, senior and voluntary roles.

9. Participants reported that the Conversations resulted in them improving in all the intended areas, The average improvement across all four outcomes was 7.2 out of 10. The trendlines show a steady improvement in these outcomes overall although there was some variation across courses as would be expected with different facilitators and different groups.

10. 93% of the comments about the Conversations were positive.

11. Collaborative partners reported that the co-production process was fascinating, enriching and empowering although quite lengthy and frustrating at times.

12. Involvement had an impact on the partners both personally and professionally. They wrote in their reflections about becoming more confident as trainers and as people and having an enhanced understanding of equity and how to effectively challenge inequity and support those experiencing inequity.

13. When asked about the impact of the project, partners wrote about observing participants changing during the courses, having received positive feedback, noticing changes in maternity and neonatal environments including increased and improved conversations about equity. They also observed that some participants wanted more answers to how to challenge inequitable practice, although they felt this would be too directive for this particular course.

14. There is a strong sense that more such Conversations are needed, more Collaborative partners, more advanced courses, more widespread courses, and that this is a model of good practice that should be shared. Consensus from the MEC partners is that a much needed ‘movement’ has started, one that allows for a complex and triggering subject to be explored safely and that it should not stop here.

15. This pilot programme has created an impactful and potentially marketable product which, given additional financial and operational support, can further impact inequities in maternity and neonatal services and beyond. It is an innovative, adaptable and scaleable model that could provide a significant return on investment.

Introduction

There is justifiable nationwide concern about the relatively poor outcomes in maternity and neonatal care for women and babies from Black, Asian and Mixed ethnic groups and those living in the most deprived areas as identified in the MBRRACE-UK reports over several years.

There is also increasing concern about poor experiences for Black, Asian and Minority Ethnic staff working in the NHS. There is strong evidence as highlighted in the People Plan that where an NHS workforce is representative of the community that it serves, patient care and the overall patient experience is more personalised and improves. To achieve this the NHS needs to recruit, retain and fairly promote staff that are representative of the diverse cultural, racial, ethnic and religious groups being served.

With all this in mind, Buckinghamshire, Oxfordshire and Berkshire West (BOB) Integrated Care System (ICS) developed a perinatal equity strategy with the overarching aims to improve:

• equity for mothers and babies from Black, Asian and Mixed ethnic groups and those living in the most deprived areas, and
• race equality for staff.

These aims are underpinned by three values, proportionate universalism, collaboration and co-production.

The strategy sets out ambitions against five priority actions to improve outcomes for these groups. Underpinning all these ambitions is the need for staff to understand why this work is required and the impacts of injustice and inequality. Alongside the equity strategy, the four NHS pledges to improve equity for mothers and babies and race equality for staff help create a shared understanding of why work on equity and equality is needed and the aims and outcomes of this work. The four pledges help ‘set the scene’ in local co-production work.

Within the equity strategy Local Maternity and Neonatal Services (LMNS) are asked to:

• equip maternity and neonatal staff to provide culturally competent care
• ensure maternity and neonatal staff experience race equality in the workplace.

This is also outlined in the NMC proficiency standards which state that midwives must be able to ‘demonstrate an understanding of and the ability to challenge discriminatory behaviour to promote equity and inclusion for all’ and consistently provide and promote non-discriminatory care.

Further, the Royal College of Obstetricians and Gynaecologists’ (RCOG) core curriculum states that doctors must ‘promote non-discriminatory practice and (be) aware of broader social and cultural determinants of health as well as an individual’s social wellbeing.’

Previous to this project, NHS clinicians were required to attend or participate in mandatory equity and cultural competency training which is delivered via short in-house or e-learning sessions . This provides information about culture and health and how these might influence healthcare outcomes. However, racial and socioeconomic disparities persist in maternity and neonatal services, as do issues around staff equality, so an enhanced approach was considered necessary.

This project aimed to enhance the current standard training with a bespoke model, which sought to further explore people’s understanding of racial and other health inequalities to help create a system wide culture where the workforce can role model a culture of belonging and deliver personalised care where service users expect to be treated equitably and as individuals. It would also ensure that the workforce can be treated equitably and have positive lived experience.

Buckinghamshire, Oxfordshire and Berkshire West Local Maternity and Neonatal System (BOB LMNS) agreed internal funding through their 2022/23 application process for an equity and cultural competence training package, to be delivered by The Jen Group LLP . This training would be offered online and system wide to the maternity and neonatal workforce. It would be an initial pilot programme with process and outcome evaluation undertaken. The intention was not to replace current standard training but to enhance this further, by skilling up the workforce to challenge and have difficult conversations.

Qualitative Feedback

Co-production

The Jen Group worked hard to support the MEC partners into a place of safety thus increasing their ability to share knowledge, experience, ideas and contribute fully. The MEC partners exhibited great individual moments of courage and authenticity. They shared their lived experience, their own unconscious bias, their fears and their hopes for a different outcome.

Group dynamics shifted as people gained new skills and confidence, designed and re-designed the programme and practiced how the Conversations could look and how they would be received.

By the time MEC partners were delivering they had become interchangeable pairs of powerhouse co-facilitators, confident both in the material on offer and on how best to support whoever arrived in the room to gain the maximum value from the day.

Feedback from the whole project team was how amazing it was to see the project through from inception to delivery, recognising their own challenges, reframing how we are taught to participate, encouraging honest and open discussion, adhering to group agreements and boundaries formed by the whole group.

Collaborative Partners

Partners were asked to respond to some broad headings in order to provide their reflections on the project. These are listed in full in Appendix 2 and illustrated with the below wordcloud.

Process

Collaborative partners reported that the co-production process was fascinating, enriching and empowering although quite lengthy and frustrating at times. Because of the sensitive subject matter it was vital to create a safe space in the Collaborative to explore aims, objectives and methods, but also, and probably most importantly, the style of delivery, the approach to language and the limits of the project, while honouring each individual’s experience and contributions. Investing sufficient time to establish these foundations resulted in a cohesive Collaborative with a strong identity and the capability to deliver the challenging Conversations.

‘I can see why true co-production does not happen often as it takes a lot of time and energy to get things moving.’

Enablers and barriers

An initial challenge for Jen Group Partners was how to facilitate getting everyone in the room at the same time, how to flex around the needs of the MEC partners e.g. other jobs, childcare responsibilities. This was managed through keeping communication channels open and throwing out ‘the rule book,’ e.g. assuring partners that talking and cooking or talking and breast feeding in a meeting was absolutely fine. This resulted in having partners free to contribute in a meaningful way thus providing a far richer and more creative conversation.

It was vital not to exploit partners, particularly those with lived experience of racial and/or socioeconomic inequity as this would be antithetical to the aims of the programme. From the outset it was decided to reimburse partners either financially or in other ways, offering flexibility to meet their individual circumstances.

‘Having been involved in other co-producing projects and struggling to get payments processed, it was a great relief that the reimbursement process was seamless.’

‘We were equal facilitators in the design and flow of the conversations’

In terms of improvements the Collaborative would have liked more forewarning of how long the process might take and what commitment it might require.

The subject matter was challenging but the group created safety to explore and to be heard and valued this safe space.

Reflections

Partners went into the project with passion about the aims but not so experienced in authentic co-production, or how long this might take.

Involvement had an impact on the partners both personally and professionally. They talked in their reflections about becoming more confident as trainers and as people and having an enhanced understanding of equity and how to effectively challenge inequity and support those experiencing inequity.

‘If anything, I’ve learned that grace is so important when walking alongside and supporting myself and others on the journey of having a better understanding of the impact that racial and socioeconomic equity and inequities have on individuals and communities. We all come from different backgrounds and experiences and humility is a key ingredient in the battle to influence.’

‘I have felt my delivery and facilitation skills have improved as a result of this work. I have worked hard on being able to sit with the uncomfortable and hold a safe space to facilitate growth in others.’

When asked about the impact of the project, partners wrote about observing participants changing during the courses, receiving positive feedback, noticing changes in maternity and neonatal environments, and increased and improved conversations about equity. They also observed that some participants wanted more answers to how to challenge inequitable practice, although they felt this would be too directive for this particular course.

They had some suggestions for next steps which were to evaluate the pilot, deliver more Conversations, bespoke Conversations for senior leaders and individual Trusts, recruit more Collaborative partners, promote the pilot as a model of good practice, attract further funding and develop a more advanced offer.

Summary

BOB LMNS must be congratulated on sponsoring this co-produced pilot programme of cultural competence and cultural safety training for midwifery and neonatal staff. This required a degree of trust in the programme leads, Collaborative partners and training participants.

The co-production process was lengthy and at times frustrating, but resulted in an authentic, impactful, marketable and scaleable product with some robust evaluation data to support its further roll-out.

Instead of a traditional course, the Collaborative’s chosen approach was to co-create Maternity Equity Conversations as safe and supportive spaces for participants to explore issues of equity and inequity. This style of learning requires a level of commitment and vulnerability from participants which the facilitators became adept at naming, role modelling and encouraging. It became clear that most people had not experienced ‘training’ in this way and took time to become comfortable and familiar with immersing themselves and reflecting rather than being ‘taught’. The process of change is uncomfortable, and these Conversations were intended to provoke change, so a level of discomfort was an important part of the journey both in the co-production process and in meeting the challenges of equity head on.

Collaborative partners could have benefited from a better understanding at the outset of how much time and commitment the project would require but overall had a very positive and empowering experience which they will take into their future lives. Genuine co-production offers a challenge to existing models of project planning and delivery, a level of trust in the process is required to allow the creative and equitable space for all involved. This can prove frustrating to those of us who are used to controlling both the pace and outcome of projects.

The uptake of the Conversations was disappointing at first but by the end there was a waiting list. As often happens with free training, there were people who booked but did not turn up. We heard that some were expected to attend in their own time, as no backfill was available. Those that did turn up reported that the course had provided improvements against the desired outcomes and that they had felt the Conversations created a safe space to explore issues of equity and inequity.

We were pleased to welcome some very senior managers into the Conversations as well as frontline staff and volunteers, and these represented all the constituent parts of BOB as well as Frimley. This blend of participants added to the richness of the learning environment. Participants of a variety of ethnicities participated and those with lived experience of racial inequity were able to share some of their experiences in the safe space created by the Collaborative, which again added to the learning.

There is a strong sense that more such Conversations are needed, more Collaborative partners, more advanced courses, more widespread courses, and that this is a model of good practice that should be shared. Consensus from the MEC partners is that a much needed ‘movement’ has started, one that allows for a complex and triggering subject to be explored safely and that it should not stop here.

‘People that have attended that have lived experience of the inequities discussed have informed me that they have found the sessions so welcome and needed. Some have reported that it is one of the first sessions that they have been able to access in their careers that have actively addressed these topics in such a safe and meaningful way.’