 Ac mae'r golygu yn gweld i'w rhai gyda Jill. Y dychu'r gydaen. Jill, rhaid i'n gyddo i'w rhaid i'r hwn fyw, ond ydych chi'n gwybod yma'n gyfeirio. Cymru yw'r unid meirio'i siadau yn y Potsmouth Hospital oedd hwn yn ei ddau'r Unedig, a Jill clwm i'r parw yn y mae cyfeirio am y llwyddon llei, bod y ffyrdd moddradd yn wneud Cymru Cynllud Llywodraeth Cymru bod yr unig yn porffol ar gyfer. is really committed to ensuring the well-being of the community midwives and became a supervisor of midwives and later professional midwifery advocate to support this. Becoming the clinical lead at Portsmouth Maternity Centre, a standalone maternity unit meant that she led a large team of midwives and strived to ensure the unit was a base of excellence for both the women and the staff. Now the community matriam, Jill, has been instrumental in setting up continuity of care and model there and Jill's going to tell us all about that now. Over to you, Jill. Thanks, Diane. So I'd like to talk to all today about how we here at Portsmouth are trying to bring back the passion for midwifery to provide safe care for mothers and their babies by implementing the continuity of care and model. Here in England we're currently undergoing a staffing crisis and a recent survey by the Royal College of Midwives reports that midwives have been driven out of the NHS by understaffing and fear that they cannot deliver safe care to women in the current system. The survey report. I think you've muted yourself, Jill. Sorry. Here in England we're currently undergoing a staffing crisis and a recent survey by the Royal College of Midwives reports that midwives are being driven out of the NHS by understaffing and fear that they cannot deliver safe care to women in the current system. The survey reports that burn out amongst midwives and, in fact, all maternity staff is higher than ever, particularly after the global pandemic which saw unprecedented levels of sickness in addition to the pre-existent shortage of midwives. Alarmingly, the highest level of dissatisfaction amongst those who were surveyed had only worked in the NHS for less than five years. We're seeing the views of the RCM echoed in our own workforce. Coming into post I inherited a community workforce who had one antenatal day per week. All their antenatal work had to be provided on this day. The community midwives rarely cared for their own women in the interpartian period. In fact, the community had seen a reduction in the labour care being offered. This was due to staff taking up specialist roles and taking up a second clinic due to the staffing levels. Historically, the community supplied one alongside unit midwife who was supported by two on-call midwives. Over the years, this changed to dedicated shifts and they were mainly worked on the labour ward. This led to a high level of dissatisfaction and sickness amongst the staff. It is rare for midwives to see their own women postnatally with the exception of maybe for discharge and this was even harder during the pandemic when the discharges were carried out over the telephone. Postnatal shifts currently are very busy and they're mainly carried out by maternity support workers and currently both the support workers and midwives are very dissatisfied with the care they're giving. In March 2016, Better Births was published and their vision was for maternity services across England to become safer, more personalised, kinder, professional and more family friendly where every woman had access to information to enable her to make decisions about her care and where she and her baby can access support that is centred around their individual needs and circumstances. For all staff to be supported to deliver care which is women centred working in high performing teams in organisations which are well led and in cultures which promote innovation, continuous learning and breakdown organisational and professional boundaries. This resonated well with the community midwives here who work in the community for this very reason. As a result of Better Births, the report for the national maternity review, there was clear recommendation that the NHS should roll out continuity of care to ensure care based on a relationship of mutual trust and respect between women and their midwives. Continuity of care is a model of care where you have a named midwife with the support of a small team who work together to provide all of your care during your pregnancy, your birth and the postnatal period. The report stated that teams could be geographically based or have teams specialising in caring for specific cohorts of women. Here in Portsmouth we decided to comply with the safer staffing levels we needed to move forward and that meant we took on the geographical caseload model. We launched our first continuity of care team, the Athena team in October 2019 before we fully understood the model. The team comprised of 10 midwives who did a mixture of full and part time hours. We knew we wanted our model to be geographical and in order to be able to facilitate the team in the area that was best placed to house them, the midwives had to take their existing caseloads with them. The area was populated by high pockets of deprivation and had the largest cohort of Black and Asian women. We wanted the team to have some control on how they worked so they were given the opportunity to choose their shift pattern. They chose to cover their work on eight hour shifts with one member of the team taking control of their roster. The 10 midwives were extremely keen and passionate about giving women scented care and set up regular meet the midwife sessions and embraced the weekly meetings to discuss the women on their caseload. They ensured the women had the opportunity to meet all of the team and placed photos of all team members within the women's handheld notes. The team were expected to cover all antenatal, interpartum and postnatal care. Never have been working this way before, the team were expected to make up hours the following day if they were not called. This could have been to cover a labour call or to cover any community midwife in the area who was off sick. Despite working in this way, the team enjoyed the relationship they had with the women and the satisfaction rate among the women was at an all-time high, in fact the very first lady that delivered with the Athena team called her daughter Athena. Then the pandemic hit, there was plenty of days when staffing was low due to sickness. Some staff were working in non-patient facing roles and some were working from home shielding. This meant that the team were called into the main unit for most of their shifts and missed a lot of their own women. They also had high levels of sickness within their own team, which meant that they weren't covered. So the pilot went on longer than anticipated due to the pandemic. We did make the decision to keep the team going because they were providing a high proportion of the labour care in relation to the rest of the community. We looked at what worked well and what didn't. Positives included the team worked extremely well together, supporting each other through difficult times, swapping shifts to help each other out, ensuring the good as well as the band. They all enjoyed the meet and greet sessions, these are specific to the continuity teams and the midwives mainly attended them on their day off. The sessions were extremely well received by both the midwives and the mothers. During the pandemic the team held these sessions over Zoom and the women found them invaluable, introducing the midwives to their partners and children to make it a real family experience. They also enjoyed discussing their women on their caseload every week, risk assessing and sharing information. The mother-midwife relationship was outstanding, again mostly during the pandemic when the women felt so lonely and isolated. The midwives really felt they were making a difference. However, some things didn't work well and negatives included the caseloads which were far too high for a continuity team. It was impossible to give the care that the midwives wanted to give when they had almost doubled the number of midwives they should have had. The midwives were also called in so many times for escalation that they missed their own women and this led to a lot of sickness within the team. It was impossible to cover all the team shifts and the labour ward escalation. The midwives were burnt out from constantly having to make up hours each week. If they were not called out on a labour call shift then they were expected to make up the shift the next day and this was exhausting. I can remember being on the labour ward in December 2020 when I saw two members of the team looking to flake it and burnt out. I asked them to go away and think of a different way of working. In the meantime, I attended a meeting with Professor Tiximacu, the National Unimidifery Lead for Continuity of Care for NHS England and it all fell into place. It was apparent we had to start over again. We started with engagement sessions which were open to all staff. We knew we wanted Athena to start a new way of working immediately but we also wanted to engage staff for future teams. We knew that the model we had so far was not working and we wanted to share that with the staff. We were able to gain lots of rich ideas and ways of working and we were also able to dispel any myths. We ensured that some of the community staff who we knew were quite vocal about not wanting to join a team were invited and in fact one of these has since joined a team and is loving the way of working. We set out some guiding principles and discussed how they would work in practice knowing that going forward these would have to be adhered to for the teams to work. The caseloads needed to be right and we needed to follow the national guidance for this. This was a huge selling point as the community midwives were used to working with high caseloads and couldn't believe they would have the time to spend with women. Equipment was also discussed and the midwives felt this was a big factor in being able to do their job properly. Training was required for all staff joining all teams, not only were we looking at compliance levels but support for labour calls both in and out of the hospital. Refreshes were given on cannulation and we carried out emergency scenario practice sessions at the local and alongside units. All the sessions were really well received and being small groups the staff found it a safe space to ask questions without feeling vulnerable. The feedback from the sessions was so positive that we've agreed to hold the sessions regularly. We advised the midwives that we would be trusting and encouraging them to work in the way that they wanted to work and they would have the time to provide the best care. So moving forward this slide shows our guiding principles. We knew that our teams had to comprise of no more than eight midwives covering 6.8 whole-time equivalents. The actual number was down to us to choose. We looked at various options but for us in terms of covering shifts and ensuring we did not burn out the midwives it worked to have eight midwives in the team. We also employed dedicated maternity support workers to support them. Case loads were set at 36 for whole-time equivalents and titrated for those working part-time although the team did work slightly more to allow for attrition. To counteract the case load numbers and ensure that the case loads did not come too high for the remaining community teams, newly qualified band fives that were interested in joining the community worked one day a week in the community with a very small case load whilst their remaining shifts were worked on the main unit. The team had to provide all antenatal intrapartum and post-natal care and would be on call for labour care as a team 24 hours a day, seven days a week. They would have to cover all sickness and annual leave. At the engagement sessions and the separate sessions with Athena the teams were all keen to cover their own annual leave and in return for this we ensured they would not form part of the hospital escalation process. The reason for this was twofold. Firstly they would not be able to cover their own escalation in the team and the escalation of the main unit and secondly we would be offering intrapartum care 24-7 and the main unit would always be able to rely on the teams to come in for their women whether that was in labour or the induction bay. To protect from the escalation process was hard initially not only was it a new way of working but it meant a whole new thought process for the band 7s running the unit. They were once they understood the process extremely supportive of the team and it is now the norm. It should be pointed out that we had the full support of our director of midwifery and without her support it would have been impossible. The midwives needed to be trusted to give the care that they wanted to give. This meant they did not have to work the following day if they were not called out and they would not be questioned. They could work the hours to suit themselves and within any time within the working month. We handed over the hours to them totally and they self-managed them. What is interesting is that the midwives tend to go over their hours to support the women rather than actually owe them. So Athena relaunched in March 2021 with the new way of working and they have completely flourished. They have worked within the guiding principle set out in the previous slide and they've proved to be the way forward. The team have been given full autonomy and they have been protected from the escalation process. The midwives are the happiest I have seen them and there have been changes within the team since they commenced with midwives moving to other areas leading for personal reasons but they're never short of people wanting to join the team. So for one year Athena cared for 242 women over the course of the year. They provided 100% of all the antenatal and postnatal care and 31 women which equated to 13% did not receive interpartum care. Of these 21 were not attended as they were already facilitating another Athena birth and 10 were not called by the unit. Whilst the team cannot be expected to look after more than one woman at a time as they are such a small team it's interesting to note that there have been many occasions where they have come in to support on their day off when two women are in labour at the same time and not being called in was a problem at the beginning of the year when we changed from paper to digital notes however this has been addressed. So you can see you can see from this graph that Athena had a slightly higher SVD rate overall than the rest of the service which in turn led to a lower assisted delivery rate and lower emergency caesarean section rate. 80% of all the births occurred on our labour ward with the remaining 20% comprising of the alongside standalone and home births. The higher SVD rate and lower intervention rate could be due to the trusting relationship between the mother and midwife knowing a woman's wishes and women being more relaxed in labour. However you will note that Athena had an elective caesarean section rate that was slightly higher than the rest of the service. This could be due to a more thorough risk assessment more meaningful conversations about mode of birth. They also have a higher percentage of Black and Asian women on the case load which will increase the elective caesarean section rate in terms of diabetes etc. I have been absolutely overwhelmed by the amount of thank you cards that the teams have been sent and hear us some quotes from the women. You have been at my side since I booked and for that I'm truly grateful. I couldn't have done this without you when you walked in the room I knew it would be okay. I had exactly the birth I wanted to avoid but having the team with me made it perfect. You knew me, you got me. We can never thank you enough. You were there for us both every step of the way and what is even more impressive is the lack of complaints. Since the teams began I've only received one complaint directly related to the continuity teams and that was because the team were unable to facilitate the lady in labour because they were already facilitating another birth. Following on from the success of Athena we decided to roll out a second team. They were given the freedom to name and provide a logo just as Athena were. Our second team hero was set up in exactly the same way as Athena with the same guiding principles. They were geographically based and like Athena based in an area of high deprivation and with the highest cohort of Black and Asian families. They were given the freedom to work their shifts, how suited them and they chose 12 hours. Hero was set up when we thought the pandemic was settling we weren't quite expecting the second wave of COVID to hit like it did. Not being as well established as Athena they did not have the luxury of the meet and greet sessions although they did manage to squeeze in an outside socially distanced meet up on the common. One of the first comments I received from Hero was how much they valued having the time to spend with women to find out what was important to them and support their choices. The feedback from both Hero and the women has been outstanding and the team really embraced the new way of working. Our third team Juno was due to be set up in October 2021, however staffing was not quite right from the point of view of the rest of the service and also the team itself. The time was right in January of this year and the team are thriving. The passion and commitment from this team is a pleasure to see. The Juno team was set up with the same guiding principles as the other teams with the freedom to work their shifts to suit the team. Some of the midwives in this team have not carried out labour care for a long time and lots of training was put into place. This together with the support of the band seven team on the labour ward has been invaluable. Years ago when the community used to go to the labour ward for a shift they would suffer huge anxiety and many went off sick. It's been uplifting to see the continuity midwives looking forward to going to work and to see the co-working that now exists between the teams and the midwives on the main unit. All of our teams have said they find the support from the band sevens running the labour ward and their colleagues on the main unit has contributed to their success. To see the main unit and community working together in this way is more inspiring. Luna, our fourth team have been waiting patiently in the wings and they launched at the beginning of April. Again the passion and commitment shown is amazing. I don't underestimate the anxiety the girls and the new teams must feel when they first launch but the smiles and the passion I see from them on a day-to-day basis confirms this is the way forward for Portsmouth. So in the one month's data here for March for the three teams the continuity teams cared for 15% of all the women under Portsmouth hospitals and over half of the black Asian and ethnic minorities who birthed in March were cared for under a continuity team. So the comments here are taking from the WhatsApp group with permission from the midwives and they're exactly the reason I came into midwifery many years ago. It was such a pleasure to be there. This is what women want. This is what midwives want. Love working with midwives who feel the way I do. The absolute best midwifery right here. My heart melted when she said she knew you would be here for her. Best job in the world. The way her contractions changed when you arrived was pure magic. These comments are exactly the reason why I believe that the continuity of care model is working. Knowing that the midwives are relighting their passion for midwifery is the most amazing feeling and the feedback speaks for itself. Some of the midwives have said to me that if they cannot continue to work in this way then they would leave the profession altogether. So occasionally things do go wrong in midwifery as we all know and the Athena team sadly had a lady who attended the maternity assessment unit with an in-tutor on death. The team immediately attended and gave the care in the bereavement suite. None of the team were familiar with bereavement care yet they did not hesitate to go in immediately and support the family. Staffing on this day meant that the team was supported by one of the midwives on the main unit who specialises in bereavement care. She emailed me the following day and this is what she had to say. Today I was caring for a lady in Nightingale and Athena lady with an IUD. Katie and Ellie came in to see her at the start of her induction and due to full staffing I was able to support them. The woman delivered and it was so lovely to see her given emotional support by midwives she knew. Gemma and Stacey took over care at the end of the shift and the main reason I'm sending this email is I was in absolute awe of the support Katie and Ellie gave each other and then the support that Stacey and Gemma gave to them both. It was a real eye-opening for me. It was so lovely and heartwarming to see such a close team of midwives supporting each other so much. I felt a bit sad it wasn't the norm. Well done Athena it was really lovely and refreshing to see. When I fed this back to the team they described themselves as being a huge comfort blanket. And as always with any improvement project we need to pause and reflect on what is happening what is going well what is not going well and where and how we go forwards. The four teams that are up and running are working well and the midwives all love this way of working so that will continue. Not all midwives will want to work in this way and we need to look at ways to bring the passion back to their environment and this is ongoing. When we first sent up the continuity plan for Portsmouth we had a staffing plan in place which meant we would not be rolling out further teams until September. However we've paused our model for the time being following the Auckland report and we will continually evaluate and when the time is right we will continue with our rollout. It is important to accept that some teams will not work and you will need to move staff around. This is not a failing this is ensuring you have the correct team to be able to support and flourish. If the teams work the midwifery will work. The experience to date has shown us that the midwives have resumed their passion for the career that they have chosen and whilst doing so they can offer the women the care they deserve. We still have a long way to go and we need to ensure that the teams work closer with their link to obstetrician where appropriate. The plan when we first launched was that the midwife would accompany the women to any obstetric appointments as deemed necessary. This has not happened to date mainly due to the pandemic. In addition the meet and greet sessions will continue. These are invaluable with a mixture of antenatal and postnatal women getting together with the midwives to share experiences. When I reflect on the things that have gone well I can't help but think the two things that we have got right and have impacted on the success are trust and autonomy. The passion has been brought back by giving the teams trust. Trusting the midwives means they have rekindled the love of their job and this is reflected in the care they give. Women want to trust their midwives. They want to feel empowered. Midwives are no different. Trusting midwives enables them to feel more valued and feel more engaged in their work leading to greater job satisfaction. The midwives working in the continuity of care teams have had a shift from working in a power-based traditional organisation into one of self-control and self-management which promotes self-confidence and enhanced decision making. This means they are happy to come to work and they know and understand their women. They have time to provide the care they want to provide. Trusting the midwives means they enjoy a culture of honesty, psychological safety and mutual respect. They are proud of where they work and they are willing to go above and beyond. Trust within a team also provides a sense of safety to expose vulnerabilities and to seek support. When you have trust in a team the individuals become stronger because they are part of an effective cohesive group. Trust is essential. A team without trust is just a group of individuals working together. Autonomy is very difficult to define and it's documented in many different ways. It's the central element in midwifery that is commonly linked with informed choices, decision making and power to control over a situation as well as having the knowledge and skills to be confident and think critically. So how have we given the midwives back their autonomy? We've given the teams the freedom to work in a way that suits them. They get to decide with the women where and when they're seen. They take responsibility for their decision making which increases their job satisfaction. They develop self-reliance and resilience, two really important leadership skills which ensures team morale remains high and everyone is motivated to perform well. Autonomous teams self-organise and decide themselves how their days will look and they're all highly involved in decision making and issues. Culture in the workplace can have a direct impact on midwives autonomy. Working in small teams where you feel confident to share and reflect at weekly meetings can only enhance autonomy by having the confidence to discuss and be accountable for your actions giving total responsibility. When midwives are supported and empowered to work in partnership with the women and have the time to offer bespoke care, they will feel fully autonomous. So how does this make for safer care? Continuity of care teams have had the time and space to build trusting relationships with the women. This means that women build up trust and have the confidence to open up enabling the midwife to support and manage any risks. Being geographically based means the teams work across high and low risk settings. The teams work closely with the practice education clinical skills facilitator and they attend formal and informal training. Effective teamwork. Whilst the women have a named midwife within the team, at least one appointment is always provided by another member of the team as a failsafe, any discrepancies that are picked up can be discussed as a team. The weekly meetings are invaluable. Here the women are discussed as a group not only to get different perspectives, but also to support and confirm the care offered. I've occasionally been present at these meetings and the team constantly reflect and learn from cases appreciating what they did well and learning where they could improve. According to the RCM, many midwives are already going above and beyond to secure the right support for their women. However, they work in areas where services are already stretched, which means they cannot give that wraparound care that some women need. Continuity of care can offer this support. To sum up, with the continuity of care model, you have more time and space to build trusting relationships and more opportunity to explore options and support informed choice. In addition, early recognition of safeguarding and mental health concerns enable appropriate plans to be put into place in a timely manner. All having a positive impact on the long-term health and well-being of women and their families, or having a positive impact on the midwives who are regaining their passion for midwifery. Any questions? Fantastic Jill, that's absolutely amazing. It's such a positive story and everybody's really, really excited about the work that you're doing and they're just saying it's so nice to have the patients and the midwives feed and how positive that's worked in your area. There are a few questions that have come up. If anybody has any more questions, please type them or you can speak to us. That's fine and you'll be happy to take those questions. One that's come up is, do you have any band five or new per sector midwives in the continuity of care teams? Yes, we do. We've had, we've trialled our first team in fact, Athena with one band five midwife and that proved really successful. The projectors work across all areas because we're so geographically based which means they gain their skills just as quickly and in some places quicker than their contemporaries because they're able to see their women through the whole journey and not pulled to other areas. We've since gone on to have a band five in each team and it's been positively received from both the midwives and the women. Excellent, that sounds so. That's working really well for you, Jill. Also another question that's come through is, do you have any students working alongside the continuity of care teams as well? Yes, we do. Each team has approximately nine students from different year groups. The students find it an invaluable experience I think and they get to build a relationship with the women and to Natalie and then they're there to see the birth as well so it's almost like they're caseloading which they really enjoy. I think there was a little bit of a problem in the very beginning because of understanding how they work. We used to say one student had a mentor and if she wasn't pulled out I think the students found it quite difficult to make the hours up. Now they don't have a particular mentor, they have the team so they find that they're getting their hours and they're getting a great all-round experience. Oh, that's really good, that's fantastic. We do have a question there from Katie who just wants to say what a lovely sounding overall team you have there and what lovely midwives to have to such leadership in you, Jill, which is fantastic. I totally agree with that, Katie. She also asks, is a caseload full-time? Is it 30-odd women did you say? Is that right? Yes, for a full 37 and a half hour contract they would have 36 women on their caseload which equates to probably three women a month and that's sort of titrate so for example if you were on a 28 hour contract you'd have 29 women per year, three for say five months and two for seven months. Fantastic, oh that's great. Another question that's come through is from Nicola, she said you mentioned you were going to try to spread this love for Midwifery to other midwives, not in these teams and how are you going to do that? So this is ongoing, I think already we're proving that if midwives are enjoying their job and we're giving them trust and autonomy then they're working so so well and I think this trust and autonomy that that we have and we should have as midwives we may have lost along the way just the way that we've worked probably across the whole of the country and I think if we just give that back to the midwives especially the trust because midwives are great, they come into this profession and they do an amazing job so to give them the trust and autonomy back they're going to enjoy wherever that is whether they're working whether that's a post-native award, whether that's a community, labour award and I think they're the two main components. I totally agree, Jill, I think you're spot on with that. In case you just want to comment that sounds amazing and so great that you've accessed help from Trixie too so that's good to have that support isn't it? Trixie's been amazing but we're really lucky that our director of midwifery is fully on board as well. And then I've got another question as well that's come through is that how do you recruit your women to the continuity teams? So because we are geographically based we literally just take the next woman that has booked so we don't we have no other criteria so we don't know what we're taking it's just the women that are in deprived areas and those of black and Asian ethnicity we would take them because we have more time to be able to address the health inequalities and then we would just take the next woman that has referred to us. Oh excellent that sounds really good. I'm just seeing if there's any more questions coming through if anyone does want to speak to Jill you're more than welcome to just put your microphone on then you'll be heard but just see there what Diana's written oh she said sadly bullying is rife in hierarchical structures and this model Jill is the only way forward given the midwives back there autonomy I think that's what Diana means there and I think you probably agree with that as well. I would and I think the way that all the midwives are working together is is just phenomenal and Katie's agreeing there just saying compassionate leadership is making the difference just out of interest does anybody out there have their continuity of care and model how is that working in your area is it similar to how it's been set up in Jill's area and don't know if anybody wants to comment on that in the chat box. Grace is just saying great here I've current positive success with this model after witnessing many failed attempts yes I think we can all relate to that Grace it's just a case of having the the power and autonomy at so many levels isn't it and having the support as well and and kind of having the foresight and acknowledgement that things will go wrong but having plan in place I just think model that you're illustrating to us during this presentation is really good of how it can work successfully I think it's fantastic. At the midwives are certainly loving it it's really nice to to see how happy they are in their jobs and looking at this morning looking at the comments on instagram and facebook where everybody's been putting up happy international day of the midwife there's just been some lovely comments from the continuity midwives saying how much they enjoy working in a continuity team and and how the care they give is just excellent so that's that makes it all worthwhile. Definitely and then Ali there is just saying um they have one team but not working as respectively um obviously being a halty due to okonom for six months um and then she just makes further comment that she's um it's just really nice good to know that it is working well in some areas and Sue max is smashing well done thank you. I mean I think that with regard to the um the fact that they have to cover their own shifts that can be hard um I think I might you know when I'm talking about that I may have brushed over it somewhat because sometimes you could be starting your shift at seven o'clock and particularly with the pandemic somebody's tested positive which means they have an hour to get somebody to cover that shift and they've managed to do it every time I mean sometimes it's been with three midwives doing four hours each um sometimes they've just straight swapped shifts but but it's worked really really well but I don't underestimate that it's really hard going sometimes. So they've got that extra compassion for each other that you can really work as a team and rely on each other that's fantastic exactly yeah. Let me just see if there's anybody have any further comments oh yeah um Tammy is coming and said joining from South Africa I work in MGP in Australia I enjoy working in this model of care and it can sometimes be challenging is MGP is that similar to the continuity of care model I think that's a lot more prevalent in Australia isn't it and been working over there for some time so that's really good it is about working working out what's working well and then sharing it with everybody else isn't it yeah definitely yeah I'm associate it is the continuity care model and then I'll just see cases typing there um and if there aren't any more questions that anybody wants to ask Jill um then I can move through to the end slides and you can move on to the next room I'll just give it a couple of minutes to see I think it looks as though some people typing there yeah Casey just wanted to say absolutely very timely presentation definitely the ethos of continuity of care is around staffing the women versus the unit and of course it's the very different way of working getting used to having autonomy over your hours takes some getting used to I'm sure yeah very important it actually did it took a lot of getting used to in the beginning um because you just feel you have to come in for every shift and you feel that you have to be there and be seen to be there um but you soon realise that that isn't the case and that you're I mean some of the girls on their days off they will go and see a woman just a one off because that's the best date that she can be seen on um and gradually that different way of working is is becoming the norm for them but it was very difficult I agree it was very very difficult in the beginning just having that flexibility isn't it yeah yes and feeling that that they were going to be asked why they weren't working on a particular day if they hadn't been called out etc but they know now that they can make it up which they do and as I said in the presentation nine times up 10 they're doing more hours than less anyway just fantastic yeah okay I think that's about all for the chat box then I can move on if you're happy do if there's anything else that you wanted to say at all before I take that presentation there no you can take that back now thank you thank you so much Jill for sharing that thank you everybody for attending it's been absolutely um really interesting and just if everyone has commented just um fantastic work and please carry on and share your model with the rest of us as well so we can all um make those adjustments