Written evidence submitted by the Royal College of Midwives (DTN0005)

The Royal College of Midwives (RCM) is the trade union and professional organisation that represents the vast majority of midwives and maternity support workers (MSWs) in the UK. The RCM is the voice of midwifery, providing excellence in representation, professional leadership, education, and influence for and on behalf of midwives. We actively support and campaign for improvements to maternity services and provide professional leadership for one of the most established clinical disciplines.

The RCM welcomes the opportunity to respond to this inquiry and our views are set out below.

How can the Government communicate the benefits of digital approaches in healthcare to the public and provide assurances as to the security of their data?

The RCM supports the wider rollout of digitisation across the National Health Service. It has real potential to improve public health as well as experience and outcomes for individuals.

Social media platforms, for example, offer new ways to communicate strong public health messages to new audiences. They reach not only large numbers of people, but people whom it can be hard to reach using old media like newspapers. The ability to target and pinpoint the people a message reaches – far better and faster than through legacy media – is a great advantage not just to those selling washing powder but to those wanting to improve public health.

Getting communications on social media right, especially apps like TikTok, is however a real challenge. The medium is a sophisticated one and any messaging and communications need to be executed cleverly and well, both so they get the message across and have effect but also to avoid the risk of appearing clunky and ham-fisted.

We were forced during the pandemic to experiment with new ways of delivering healthcare, and many of these were successful. In antenatal care, for example, there were opportunities to deliver virtual sessions that are accessible and inclusive. They were able to be recorded and accessed at times that suited women.

In terms of antenatal and postnatal online consultations, it is ideal for this to be in-person but for some women, for example those living in remote and rural areas, there could be some benefit to conducting at least some consultations online. Online consultations can also facilitate multi-disciplinary consultations where a woman can speak a number of different clinicians quickly and easily or even at the same time.

Finally, a woman could call a triage service using a mobile phone or tablet before coming into hospital, which could reduce the number of unnecessary visits to hospital and waiting times within units.

There is however, as the question implies, issues around selling the idea of more digital approaches to healthcare to large sections of the public who may be more sceptical about it. Are people, for example, happy to see a consultant virtually rather than in-person?

This will be a difficult challenge because many will want to keep dealing with the NHS in the same way as they have done for decades.

The only real and sustainable way in which to move public opinion is through solid evidence that more digitalisation means care that is just as safe, if not safer, and that services may even improve – if, for example, waiting times to speak to a specialist tumble if they can see patients more efficiently and speedily in a virtual way. Perhaps service will even improve because the time clinicians would have spent waiting for the next patient to be found and brought into the consulting room could instead be used for more face time, albeit virtual, per patient.

Another potential example would be if AI could clinically assess scans or test results faster and more accurately than a human clinician could.

This strikes the RCM as the only real way to convince sections of the public who might be sceptical about more digital delivery of healthcare to welcome it. Likely it will not be a fast process, but the benefits are potentially large – both in terms of financial savings that could be better invested elsewhere in the system and also outcomes for patients.

The same goes for security of data. The proof that it is safe will be that it is safe. False or overblown reassurances will backfire if and when security of data is breached. The only way to address this is to be frank with the public about any potential risks, but also the potential benefits – paper files that can be leafed through by staff without any paper trail that they had looked is far from perfect. Additionally, the system just needs to prioritise data security and get it right.

Overall, the best way to prove that it is good for patients and the data is safe is to walk the walk as well as talk the talk. The best way to convince people is, simply, to improve their care and keep their data safe.

What progress has been made in digitising health and care records for interoperability, such that they can be accessed by professionals across primary, secondary, and social care?

Enabling those and only those with a legitimate need to view patient records or notes – individuals such as GPs, health visitors, community midwives, social workers, and others – is vital in delivering effective care, supporting robust information governance, and ensuring data security.

It has the potential to save time and money, thus freeing up resources that can be used to deliver more and better care and to care for more people more quickly.

The rollout of Connected Care in parts of England is an example of progress that has been made in joining up information sharing between primary and secondary care. Connected Care is a locally secure IT system used by primary and secondary health organisations, to share service user's relevant medical information conditions and needs. The system enables instant, secure access to parts of the service users medical and social care records for professionals involved in their care. In relation to midwifery, GP’s who offer shared care in primary care settings and midwives looking after women in secondary care settings can view the same information about a woman. Documents such as discharge summaries can be sent to connected care which means that pregnant women no longer have to repeat their medical and pregnancy histories time and again. Which in turn reduces the risk of harm that could result from missed information.

This is an example of the great strides that have been made in the digitisation of maternity records and their integration into Trust-wide systems. However, In the most recent (July 2021) Digital Maturity Assessment (DMA) there is still wide variation across England in terms of how digitally mature maternity services are and their level of interoperability.

It is frustrating in the extreme however and even a little bizarre that the NHS is not much further down the road of creating digital systems that can work together across sectors of care and across the entire National Health Service. The DMA results has identified that there is still significant work to be done in attempts to standardise the disparities in digital offering across England and ensuring all women accessing maternity services are given the optimal care.

What are the principal considerations that should be taken into account in this context and what additional training of the workforce will be needed to achieve this?

Central to driving forward the digital transformation of NHS maternity care is digital leadership. There needs to be a clear focus on digital leadership at every level of the maternity service, to drive change and secure its adoption within the system.

We recommend that digital midwives are employed in every maternity service to ensure that the NHS locally is harnessing the potential for service improvement offered by digital transformation.

That said, digital transformation is everyone’s business and should not fall solely or disproportionately on the shoulders of digital midwives or otherwise digitally savvy individuals within the team.

Indeed, digital skills and an understanding of digital transformation is something that everyone in the maternity workforce (as well as the NHS workforce more broadly, of course) needs to possess. To that end, the maternity workforce would benefit from engaging in digital literacy and digital competency assessments. An individual’s digital confidence and capabilities are bound to vary, therefore a standardised approach to training runs the risk of either being too advanced or too elementary for many members of staff.

Training needs to be tailored based upon the results of an assessment of the individual’s capabilities. This process need not be burdensome and can be facilitated through online eLearning modules specific to the individual’s needs. Likewise, if available, group face-to-face teaching sessions can be a valuable way of training clinical staff with similar starting levels of skills and competence. Ultimately, understanding individual training needs and tailoring training towards those needs is most effective.

A greater focus on learning and role modelling best practice, from the best at home and abroad, should be encouraged. The system can identify maternity services that are thriving digitally and considered to be digitally mature, using the July 2021 DMA.

Training of the maternity workforce should also focus on multidisciplinary team learning. As with most training in maternity care, an emphasis on team knowledge, capabilities and skills is essential. When a new electronic system is being rolled out in a Trust, for example, there can be benefits derived from group learning. Champions can also be identified at this time who will go on to support others in the clinical area.

Finally, there is an urgent need to educate staff on the use and collection of data. Improving data collection and linkages between maternity and other clinical data sets is essential for improving the quality of maternity care. Anecdotally, clinicians are often not aware of the importance of correct data entry at the point of care, with only mandatory questions on the Electronic Patient Record being completed. More complete and robust records enable benchmarking and can drive a continuous focus on prevention and quality.

How can the creation or exacerbation of digital inequalities be avoided when implementing digital transformation?

The focus of any maternity digital strategy must consider the perspective of the end user, and any recommendations must support solutions which are coproduced by service users and clinicians. This is one of the steps in ensuring wider acceptance and minimising digital inequalities.

Engaging stakeholders from the onset includes those that are on the frontline, delivering the care. Clinicians on frontline are often the last ones to be informed of the rollout of new technology within their department, and often the ones whose working lives are most affected by it. They are also often individuals who may well be best placed to advise on what will work and what will not work for women from different groups and backgrounds as they are the members of NHS staff who are most often speaking with those women face-to-face.

We frequently hear this complaint from midwives across the service that technology over which they have had little say or input has been thrust upon them. This has the potential to create resistance to it from the very start, as well as a higher risk that the system is not what will work best for all women.

Digital solutions must provide a joined-up experience for women and families, where they only have to tell their story once and feel confident that up-to-date information is flowing safely between care settings and chronological stages of development or pathways of care.

Covid has also demonstrated that technology is not one-size-fits-all. At the height of the pandemic pregnant women were moved on to virtual appointments as they were classed as vulnerable and could not attend face-to-face appointments. Virtual appointments required women to own a digital device, register on the communication platform, authenticate through email, and log on to the appointment. Although these steps may seem easy and straightforward for the majority, there is a subset of the community that may struggle with this. Especially those for whom English is not their first language or those who are not digitally literate.

For these women digital solutions may not suit their needs and hybrid or alternative systems (including paper-based systems) may well need to continue to run in parallel, alternatively digital workshops may work in upskilling those who are willing and able to participate. These workshops act as drop-in sessions where women can attend and access help for their future digital appointments. Likewise, the use of apps that are more widespread within the community and which work easily and securely on mobile devices may be beneficial.

The digitisation of maternity records should require engaging with women using maternity services. Representatives (such as Maternity Voice Partners) should be involved at the starting point of such projects. To understand the needs of all women and deliver a product that meets those needs.

Conclusion

The wider rollout of digitisation across the NHS has real potential to improve public health as well as experience and outcomes for individuals. However, convincing large sections of the population of the advantages of digital approaches requires solid evidence that digitalisation will result in safer and better care and that any risks associated with data security are more than outweighed by the benefits.

While progress has been made in achieving some interoperability across primary and secondary care, and in the digitisation and integration of maternity records, significant work is still needed to create digital systems that can work together across sectors of care and across the National Health Service as a whole.

There needs to be a clear focus on digital leadership at every level of maternity services and digital midwives need to be employed in every service. That said, digital transformation is everyone’s business, and the entire maternity workforce would benefit from engaging in digital literacy and digital competency assessments.

While training should be tailored according to an individual’s capability, training should also focus on multi-disciplinary team learning. There is also an urgent need to educate staff on the use and collection of data.

In order not to create or exacerbate digital inequalities co production and digital inclusion with clinicians and service users must be central to all technology being used and to be used in the future. Engaging these key stakeholders from the initiation/planning stage will go a long way to identify and understanding their needs and get their buy in.

June 2022

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