Enhancing sustainable value of the first obstetric antenatal appointment (Green Maternity Challenge)

Project completed as part of the National Green Maternity Challenge 2024-25 by the team at Imperial College Healthcare NHS Trust.

Enhancing sustainable value of the first obstetric antenatal appointment: Project is a part of the 2024 Imperial College Healthcare NHS Foundation Trust Green Maternity Challenge.

Team members:

• Marisa Taylor-Clarke, Obstetric Consultant, QCCH, Project Lead
• Mene Tzafetas, Safety Improvement Fellow and O&G ST5, QCCH, Project Lead
• Violet Conidi - Outpatient Supervisor, QCCH
• Emily Barrow, O&G ST7, QCCH
• Shahanaz Rahman, Maternity Outpatients Ward Manager, QCCH

Setting / patent group: Maternity Services

Issue: 

From a previous audit at Queen Charlotte and Chelsea Hospital (QCCH), it was identified that approximately 20% of the Obstetric led antenatal appointments made are unnecessary face to face appointments for women in the first trimester. They are identified as requiring Obstetric led care at midwife booking for various reasons based on by past history such as a past Caesarean Section, previous ‘small’/’large’ baby, previous PPH as well as some duplication of appointments for patients who are seen by multiple specialties.

Such women are usually seen by a consultant later as well. During the first trimester, although risk assessment, history taking, explanation and counselling are required, physical examination or urgent additional investigations are rarely necessary. Hence, arranging for such appointments routinely in the first trimester can be inconvenient for the women. It can also create frustration associated with waste of time in attending appointments and this can affect attendance rates for appointments at later gestational ages. Further, a busy clinic might not permit the consultant to do necessary counselling, necessitating another follow up appointment which causes further wastage of resources, and staff time. Appointment availability for other pregnant women is also affected due to this, so much so that there is no capacity for urgent or time sensitive appointments. The key issue is ‘valuing of time’ for both patients and healthcare staff.

Intervention: 

The main aim is to increase the sustainable value of appointment for the above-mentioned population of women in first Trimester pregnancy, by making use of virtual consultations as compared to in person appointments. By project mapping and staff engagement, an attempt was made to understand the key issues and generate ideas for change. A new triage process was implemented called Obstetric Consultant triaging, for new obstetric antenatal appointments at <24 weeks received from the QCCH antenatal clinic midwives via outpatient admin supervisor. The time taken for triaging was around 2-3 hours per week. Telephone appointments were suggested for women based on a set criterion. Pilot telephone clinics were started and after an initial 2-week period, a consultation template was created to ensure a standardised approach to the appointment to increase the consistency and approach across different clinicians. Telephone clinic capacity is being planned to be expanded along with amending obstetric clinic referral system to include indication to facilitate triaging. Indications for appointment will also be explained to patients and referral criteria in local guidelines will be reviewed.

Outcomes: 

Environmental

The carbon footprint for an in-person ANC is 12.96 kgCO2e/person which reduces to a mere 0.1 kgCO2e/patient for a telephone ANC. Over t00he duration of the project, a saving of 933 kgCO2e has been made and this makes an annual saving of 24,262 kgCO2e.

Social

83% of the woman surveyed preferred virtual service over attending in person appointments because of several benefits such as having to take less time of work, ease with childcare, avoiding frustrating waiting times at clinic, and partner being able to participate in the appointment. It also saved an average of £11.35 in transport per patient. Staff motivation and satisfaction in improving antenatal care is also an added benefit that has been reported.

Clinical

Efficiency of maternity services can be improved, and it can be made more person centred, whilst also improving perception among women about the purpose of the appointment. Care can be delivered on time and there was a high perception value of online appointments among patients.

Financial

While calculating savings, staff cost was excluded as the staff would still have to remain on site for existing in person clinics. Keeping that in mind, a small cost saving of £1 per appointment was calculated based on savings from consumables, water, and energy equating to a total of £1,872 annual savings. During implementation of the project, staff costs for training are calculated to be around £300/week. But when considering the overall sustainable value and the costs associated with incident investigations, complains and litigation, this seems to be a negligent amount to bring a huge impact.

Key learning point:

The project demonstrates significant sustainable values, particularly with regards to social and environmental impact. Team engagement and commitment, regular review and communication and strong support from senior management for this project has led to the success of this project so far. A long-term project like this is crucial in a climate of negative public and policy perception to provide hope and motivation to the staff and the public. Projects like these provide an opportunity not just for personal development of the staff but also to focus on engaging patients and wider community with optimism and innovation in healthcare to safeguard global health and future.