“Someone's rooting for you”: Continuity, advocacy and street-level bureaucracy in UK maternal healthcare

Social Science & Medicine 69 (2009) 1228–1235

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‘‘Someone’s rooting for you’’: Continuity, advocacy and street-level bureaucracy in UK maternal healthcareq Susanna Finlay, Jane Sandall* King’s College London, London, United Kingdom

a r t i c l e i n f o

a b s t r a c t

Article history: Available online 21 August 2009

Continuity and advocacy are widely held to be important elements in maternal healthcare, yet they are often lacking from the care women receive. In order to understand this disparity, we draw upon interviews and ethnographic observational findings from The One-to-One Caseload Project, a study exploring the impacts of a caseload model of maternity care within an urban National Health Service provider in Britain. Drawing on Lipsky’s (1980) and Prottas’s (1979) theories of street-level bureaucracy, this paper attempts to understand how midwives, working on the frontline within caseload and standard care models, manage the competing demands of delivering a personalised service within a bureaucratic organisation. The caseload care model serves as a case study for how a client-centred model of working can assist street-level bureaucrats to manage the administrative pressures of public service organisations and provide their clients with a personalised, responsive service. Nevertheless, despite such benefits, client-centred models of working may have unintended consequences for both health carers and healthcare systems. Ó 2009 Elsevier Ltd. All rights reserved.

Keywords: UK Street-level bureaucrats Advocacy Maternity care Continuity Midwives

Introduction The importance of continuity and advocacy in maternity care has been discussed in high income countries for more than a decade (McCourt, Stevens, & Sandall, 2006; Haelterman, Qvist, Barlow, & Alexander, 2003; Esposito, 1999). Nonetheless, maternal healthcare is often found to lack these elements (Homer, 2006; Murray & Bacchus, 2005; Tiedje, 2005). An example of this predicament can be seen in the United Kingdom (UK) where around 99% of women receive their maternity care through the National Health Service (NHS). Within this context, healthcare workers face the dilemma of trying to deliver policy objectives of personalised maternity care (e.g. Department of Health, 1993; Department of Health, 2007; Department of Health, 2008b) whilst working within a bureaucratic system designed for processing people en-masse. Such dilemmas have been highlighted by Prottas

q We are very grateful to everyone who participated in this research, and to The Guy’s and St Thomas’ Charity for funding the project. We would also like to thank Susan Fairley Murray, Susan Bewley and Myfanwy Morgan for their comments on earlier drafts of this article. * Corresponding author. King’s College London, NIHR King’s Patient Safety and Service Quality Research Centre, Floor 7, Capital House, 42 Weston Street, London SE1 3QD, United Kingdom. Tel: þ44 207 848 3605. E-mail address: [email protected] (J. Sandall). 0277-9536/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2009.07.029

(1979) and Lipsky (1980) in their investigations of the workings of public services. Street-level bureaucracies Bureaucracy, as defined by Weber, refers to ‘‘a hierarchical organisational structure designed rationally to co-ordinate the work of many individuals in the pursuit of large-scale administrative tasks and organisational goals’’ (1949, cited in Slattery, 2003:28). The attributes of a modern bureaucracy include its impersonality, specialisation, hierarchy, and consistent regulation (Slattery, 2003). In the 1970s, political scientist Michael Lipsky coined the term ‘‘street-level bureaucracy’’ to denote bureaucratic public service organisations that deal face-to-face with citizens/ clients. Consequently, the term ‘‘street-level bureaucrats’’ refers to all frontline workers within such organisations ‘‘who interact with citizens in the course of their jobs, and who have substantial discretion in the execution of their work’’ (Lipsky, 1980:3). Street-level bureaucrats work within tightly scheduled and fragmented systems that often do not allow enough time to sufficiently deal with the needs of clients and, due to a lack of continuity, frequently do not support workers to take responsibility for their clients. Examples of street-level bureaucrats are teachers, social workers, police officers and healthcare workers. Lipsky (1980) and Prottas (1979) argue that the organisations that employ these workers possess significant similarities which shape both the processes

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through which they conduct their work and the dilemmas they face in attempting to fulfil the competing demands of the organisations and their clients. These demands, to provide services efficiently to a large number of people, while also providing individualised attentive service, form what Lipsky deems ‘‘the fundamental service dilemma of street-level bureaucracies’’ (1980:44). One such demand is for street-level bureaucrats to act as their clients’ advocates. However, while this is articulated in professional training, the structure of their work and the fragmented nature of their relationships with clients undermine their ability to advocate (Lipsky, 1980). What do advocacy and continuity mean? Both advocacy (Foley & Platzer, 2007; Goold & Klipp, 2002; McLean, 1995) and continuity (Armstrong, 1985; Bramesfeld, Klippel, Seidel, Schwartz, & Dierks, 2007; Woodward, Abelson, Tedford, & Hutchison, 2004) have been discussed by social scientists for some time. However the meanings ascribed to these terms are contested. Definitions for advocacy have ranged from guarding clients’ rights to autonomy and free choice (Feltes et al., 1994), to seeing one’s role as advocate as a mission to serve in clients’ best interests, sidestepping all obstacles in one’s path (Segesten & Fagring, 1996). Lipsky however assigns a broader definition to the term. He states that for someone to act as an advocate they must ‘‘use their knowledge, skill, and position to secure for clients the best treatment or position consistent with the constraints of the service’’ (Lipsky, 1980:72). However, in order to do this they must be able to ‘exercise their discretion’. Here then we refer to advocacy in the sense ascribed by Lipsky, examining how different situations see midwives utilising their knowledge, skills and positions to advocate in different ways. In terms of ‘‘continuity’’, Freeman et al. (2007) capture much of the diversity of meaning in their review of the subject. They define three main types of continuity: informational continuity, management continuity and relationship continuity. Here we use the term to refer to the latter form, relationship continuity. Thus the model of continuity explored and discussed below is based on an ongoing, trusting relationship between each woman and a midwife who assumes personal responsibility for her care throughout pregnancy and the childbearing period. Healthcare workers as street-level bureaucrats The application of the concept of street-level bureaucracies, the issue of people-processing and the dilemmas and conflicts highlighted by Lipsky and Prottas are the subject of a growing body of literature within the healthcare arena (e.g. Allen, Griffiths, & Lyne, 2004; Griffiths, 1998; Meershoek, Krumeich, & Vos, 2007). Such studies have focused on the routines and simplifications used by health workers to ‘‘process’’ people; the coping strategies they develop to deal with their resultant work frustrations, and the resultant implications for implementing policy on the frontline (Checkland, 2004; Hughes & Griffiths, 1999; Walker & Gilson, 2004). However, this literature has yet to pay much attention to the strategies developed by services and professionals to enhance the frontline health professional’s ’exercise of discretion’ within bureaucratic healthcare systems. Maternity is an area of healthcare in which such dilemmas are quickly visible. In the UK, for example, midwifery training places strong emphasis on ‘independent practitioners’ and their advocacy roles (Nursing and Midwifery Council, 2008; Page, 1995). Hunter (2004) and Walsh (2006) have both drawn upon Lipsky’s theory to consider modes of midwifery practice in out-of-hospital settings in the UK and have suggested that greater exercise of discretion is

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possible in those settings where the organisational imperative is less overt. This paper takes up this argument and explores it through a comparative study of the operation and effects of two different models of maternity care, implemented within the same organisation within a defined catchment area. It examines the effects of the different models of care both on the street-level bureaucrats’ themselves (the midwives) and on their women clients. The study A recent Cochrane review concluded that women’s experiences, as well as their clinical and psycho-social outcomes, are improved through receiving continuity of midwife care throughout the pregnancy and childbearing period (Hatem, Sandall, Devane, Soltani, & Gates, 2008). The data below is drawn from The Oneto-One Caseload Project, which was designed to test the feasibility of such a service innovation and organisational change in UK maternity care. The institutional setting was a large urban maternity service provider within the NHS, which serves a mixed population in terms of ethnicity and social class. The ‘‘standard model’’ of maternity care within this hospital was, at the time of this study, a routinised community midwifery service where women received care from whoever was on duty. The study compared and contrasted this model with an innovative community midwifery service, the ‘‘caseload model’’ of care, within which women were assigned a personal midwife who was responsible for providing and co-ordinating care from pregnancy through to the postpartum period. To test the feasibility of this model of care, three caseload group practices of 6 midwives, each with a structure and philosophy aimed at supporting relationship continuity, were set up in areas of deprivation (determined by the Index of Multiple Deprivation (Office of the Deputy Prime Minister, 2004)). Midwives in both the caseload and standard care models were contracted to work the same number of hours, however the organisation of their work was very different. Each caseload midwife held an annual caseload of 36 women of mixed-risk for medical and obstetric complications, drawn from a postcode-defined geographical area. These midwives worked in partnerships within which they aimed to provide 24/7 labour cover. In contrast, the standard care model involved midwives and General Practitioners (GPs) providing women with shared care. Thus, rather than having a named midwife, women’s maternity care was provided by community midwives who staffed antenatal clinics and provided postnatal visits within a geographical area, and by hospital midwives who provided labour support. Therefore, women receiving care under the standard model often saw a large number of midwives and GPs throughout pregnancy, birth and the postnatal period, while women receiving care in the caseload model saw their midwife and partner (with the support of other providers when appropriate). Overall, 21% of women received caseload care and 71% received the standard model of care. The remaining 8% received team midwifery care. Under this model, women receive their antenatal, intrapartum and postnatal care from a group of midwives. The model provides less relationship continuity than caseload care, but potentially more than standard care (Healthcare Commission, 2008). It is not discussed in this paper. Methodology Following ethical approval from a NHS Research Ethics Committee and NHS R&D approval from the Trust where the research was carried out, a mixed methodology was utilised to explore the impacts of the service change as it occurred within the hospital. The qualitative data used in this paper are drawn from this

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wider methodology. In combining elements of ethnographic and interview-based research, the approach utilised bears similarities to that advocated by Brodkin, the objective of which is to assess street-level practice in terms of its own internal logic by utilising a ‘‘systematic examination of both the conditions of work and the content of practice, moving heuristically between the two in an effort to explain the particular form that implementation takes in specific settings’’ (2001:13). Data collection took place from January to August 2006. Nine midwives were recruited to take part in ethnographic observations, four from across the caseload group practices and five from different standard care practices. The researcher observed each midwife throughout a day’s work, travelling with them between appointments and between hospital and community settings. Women whose appointments fell on these days were given the opportunity to ask questions about the research before giving their permission for their appointment to be observed. In order to minimise the impact of her presence on the interactions observed, the researcher spent time building rapport with the midwives before and between appointments, and took on the role of an assistant during them. Furthermore, she refrained from taking notes during the observations, as these can be disruptive and disconcerting for participants, taking instead ‘‘headnotes’’ which were recorded immediately after the conclusion of the day’s observations (Emerson, Fretz, & Shaw, 1995). In addition, semi-structured, face-to-face interviews were undertaken with 17 midwives and 14 women. Purposive, heterogeneity sampling was employed in order to capture a diverse sample of opinions and experiences. Accordingly midwives were recruited from all areas of the service, with varying lengths (9months-35years) and types of experiences. Likewise women, recruited equally from the caseload and standard care practices, were chosen to represent a range of ages (19–39 – caseload care mean ¼ 30, standard care mean ¼ 33), parities (1–3 – caseload care mean ¼ 1.9, standard care mean ¼ 1.6), socio-economic backgrounds (determined from demographic data supplied in a postnatal questionnaire) and ethnicities. Representative samples of women from white British, black British, ethnic minority, and other ethnic groups were selected for the caseload and standard care interview groups. The interviews were undertaken in privacy at times and locations nominated by the participants. Written consent was obtained and each interview was audio-taped and assigned a unique, confidential identifier (names assigned in this paper are pseudonyms). The tapes were transcribed verbatim and the transcripts and ethnographic fieldnotes were managed using NVivo 7.0 software. Each transcript and fieldnote entry was coded for emergent themes and then compared to previous transcripts and fieldnotes using the constant comparison method (Glaser & Strauss, 1967). As the process of coding was concurrent with the interview and observation periods the focus of subsequent observations and interviews changed in order to further investigate the emerging themes (Strauss & Corbin, 1990). The most common of these emergent themes are presented below. Findings Continuity, discretion and personalised care The caseload practices had been set up with the specific aim of establishing relationship continuity between midwife and maternity service user throughout pregnancy and the childbearing period. The importance of relationship continuity has been identified in many areas of healthcare (e.g. Freeman et al., 2007; Woodward et al., 2004), including maternity care (Davey, Brown, &

Bruinsma, 2005; Huber & Sandall, 2006; McCourt et al., 2006). However, our interest in this paper is to examine whether improved continuity also lays the groundwork for improved provision of advocacy, as well as whether, and how, it contributes to shift the nature of street-level bureaucrats’ work away from a people-processing model. Under the standard model of maternity care, midwives’ interactions with women appeared to be influenced by the bureaucratic tendency of hospitals to ensure that ‘‘professionals conform to a relatively protocol driven model of action’’ (McCourt, 2006:1317). As one woman noted: [The midwife was] very attached to her questions, like the first appointment, which is very long, you ask many questions, it was like dah, dah, dah, she didn’t want to know about me, didn’t even look at my face (Maria, standard care, second baby) This almost automated style of working, which was both frequently observed and highlighted in interviews by women receiving standard care, is common among street-level bureaucrats. Both Lipsky (1980) and Prottas (1979) discuss it in terms of the routines and simplifications street-level bureaucrats use to process their work. In other words, the methods they use to process people. Potential explanations for such behaviour include a focus on efficiency or an avoidance of emotional engagement. However regardless of reason, Maria’s disappointment at being treated in this way indicates that such behaviour can have a detrimental effect on women. The conflict between the needs of the organisation and the needs of women was pervasive throughout the standard care model. This struggle, as Lipsky writes, is fundamental for ‘‘streetlevel bureaucrats must find a way to resolve the incompatible orientations towards client-centered practice on the one hand and expedient and efficient practice on the other’’ (1980:45). In the case of these midwives, their dilemma appeared to lie in the conflicting demands of the maternity health service to process an increasing number of women, and the needs of those women for tailored, responsive care. As Celia put it: You’re up against this machine of the NHS and these constraints you’ve got to work in and you can’t give [the women] what they want (Celia, standard care midwife) This conflict was observed in many of the interactions between women and midwives working in the standard care model. Donna, for example, saw a woman for a booking appointment who had a history of serious back problems. This woman expressed a desire to see a consultant to discuss the implications of the pregnancy for her condition and her choices of pain medication. Donna however replied that such an appointment was unnecessary and could wait. It seemed, from comments that she later made, that the reasoning behind Donna’s response was that the service was already overstretched. Referring this woman would stretch the service even further and create more work; however not referring her ignored both her expressed need for care and hospital policy. Given that the midwives working within the standard model of care did not have any continuity with, or overall responsibility for, the women they saw, it is arguably unsurprising that their allegiance was at times closer to the organisation and its needs to ration available resources, than to their individual clients. From the organisation’s perspective, this prioritising of impersonal rationing over individualistic advocacy could be viewed as a positive repercussion of standard care midwives’ lack of personal obligation to individual clients, an issue addressed in the discussion. In contrast, under the caseload model midwives appeared more able to avoid the constraints of the healthcare system. This increased ability to exercise discretion, and/or increased sense of

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personal obligation, was used by many of the caseload midwives to tailor care to women’s needs, as indicated in the following fieldnote excerpt. The next appointment was with a woman who was only 17 weeks pregnant. She had been booked at 9 weeks and had been seen again at 13 weeks by Beth, which was interesting as most women would only have had two, rather than three, appointments by this point. The woman however was very anxious about her pregnancy and had lots of questions, so Beth had booked in the extra appointment (Observations with Beth – caseload midwife) Further examples of the caseload midwives tailoring women’s care included: adjusting the length of the postnatal care period to accommodate women’s needs, scheduling special debriefing appointments with women following their meetings with consultants, and negotiating women’s pathways through the hospital system. This tailoring of care, which was not witnessed within the standard model, marked a shift towards midwives prioritising the needs of women over the needs of the service. This finding is supported by McCourt who writes, ‘‘innovative models of midwifery, such as caseload practice, can offer more choice and control to women, partly through continuity of carer in itself but also since this appears to facilitate a primary orientation towards the ‘client’ and her community, rather than towards the institution’’ (2006:1317). However, orienting the street-level bureaucrats’ focus towards the needs of the client and away from organisational needs can come at a cost, as it did for Amy: One of Amy’s women has had a lot of issues since her baby was born which have really thrown her and made her very needy so that Amy spent 4 hours with her one day. This was very draining for Amy (Observations with Amy – caseload midwife) The standard model of care, with its time limits on appointments, provides some measure of protection against demanding relationships with women. However midwives working within this model struggled to provide women with the individualised, responsive care they had been trained to deliver (Nursing and Midwifery Council, 2008). Thus they often had to give up their own time, unpaid, if they wished to provide such care. Tina had a booking clinic in the morning and a follow-up clinic in the afternoon and she still did a postnatal appointment in her lunch hour. A couple turned up with their six day old daughter without an appointment. They had not received any postnatal visits so had many questions and were concerned to know that their baby was OK. Tina could have told them to book an appointment, or to wait for a midwife to visit them, but instead she spent her lunch break checking the baby and reassuring the parents (Observations with Tina – standard care midwife) As Lipsky writes, ‘‘although street-level bureaucrats may sometimes struggle to maintain their ability to treat clients individually, the pressures more often operate in the opposite direction’’ (Lipsky, 1980:100). Thus the disruption of work-life balance, as experienced by Tina, may act as a deterrent to providing such care. Continuity and advocacy Lipsky writes that street-level bureaucrats often find it difficult to act as advocates for their clients despite this being an expected part of their role. The reason for this tension, he asserts, is that the structure of street-level bureaucrats’ work and relations with clients ‘‘compromise altruism and undermine advocacy’’ (1980:73). However, while this tension is indeed present in the standard model of midwifery care, it is not as pervasive within the caseload model. Consequently, just as it is not inevitable that street-level

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bureaucrats working within healthcare will prioritise the needs of the organisation over those of the clients, neither is it fated that they will be unable to act as advocates. One element of this tension, identified by Lipsky, concerns the size of street-level bureaucrats’ caseloads and the time they have to dedicate to each client. He notes that advocacy must be delivered on an individual basis, and that it ‘‘may be compromised by large case loads and mass processing of clients’’ (Lipsky, 1980:73). This was arguably the case for the midwives working in the standard model of care for whom time was a scare commodity and caseloads were large, two elements that encouraged midwives to ‘‘process’’ women as quickly and routinely as possible. As one woman noted: You don’t have time to ask the questions I needed to ask. I said I need help to write my birth plan, to see the options, and to have some advice, what is good. She said, ‘‘Sorry, I don’t have a lot of time now.’’ Just an examination and blood pressure, urine sample, and that’s it (Alessandra – standard care, first baby) Thus, although the midwives attempted to provide women with good quality care, the structure of the standard maternity system was restrictive in this respect. Short appointment times and a lack of continuous, trusting relationships with women was found to have a detrimental impact on the care they gave and their ability to ‘‘use their knowledge, skills and position’’ to advocate for women. During several observations midwives working in the standard care model skipped over routine questions, or avoided explaining tests or issues to women in order to get through the appointments in the allotted time. The process of cutting corners was so ingrained that on more than one occasion midwives were observed reprimanding student midwives for following the good practice guidelines for conducting appointments, as doing so resulted in appointments running overtime. However, in cutting corners in this manner, and in ‘‘processing’’ women quickly, several of the women were left feeling as Alessandra and Jenny did. I didn’t feel like they were really bothered. Not bothered, that’s the wrong thing to say, but it wasn’t like they were trying to get any information out of you or necessarily trying to make you feel comfortable enough to talk about things (Jenny – transferred from standard to caseload care, third baby) In contrast, the caseload midwives’ model of work was more flexible, and allowed them to manage their own time to a greater extent. Hence like many others who experienced caseload care, Katie felt that her midwife was able to give her the time she needed. I never felt rushed or that I couldn’t ask questions; it was brilliant (Katie – caseload care, first baby) Thus within the standard model of care, if not within the caseload model, Lipsky’s assertion that a lack of time undermines the provision of advocacy holds true. For Jenny and Alessandra, their midwives’ lack of time prompted them to avoid engaging with the women on anything more than a superficial level. The following fieldnote excerpt also highlights how a lack of time, a lack of adequate staffing, work overload, and arguably a lack of perceived responsibility towards individual women, can prompt midwives to avoid extra work even when doing so is detrimental to their clients. There was supposed to be a parent-craft session this afternoon but, as none of the midwives were willing or able to do it, they decided to tell the women who had turned up that the midwife, who was going to take the class, had been called to a homebirth (Observations with Lynn – standard care midwife) This type of behaviour is often perceived to result from ‘‘laziness, inertia, and inability to plan’’ (Lipsky, 1980:126). Conversely, Lipsky

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argues that it results from street-level bureaucrats’ need to protect themselves from being overloaded with work. He reasons that, as efficiency within bureaucracies is not rewarded with time gained for other tasks, but rather is often filled with further assignments, there is no incentive to either be efficient or to volunteer for extra work. Arguably neither is there an incentive to act as an advocate when, in the absence of responsibility for clients, you can ‘‘pass the buck’’ to the next in the production line along which the client is passing. The standard care midwives’ lack of overall responsibility for the care of the women they saw was, we argue, a product of the lack of continuity in the model of care, which in turn also made it difficult for the midwives to act as women’s advocates. This lack of continuity, responsibility and subsequently advocacy, at times led to women missing out on much needed information and choices. For example, only one of the midwives observed working in the standard care model emphasised women’s option to have a homebirth during booking appointments, despite this being a national and local requirement (National Institute for Health and Clinical Excellence, 2008; Department of Health, 2008b). The others appeared to assume the women would give birth in the hospital, so simply asked them whether they wanted to go to the midwife- or the doctor-led birth centre, a ‘‘choice’’ that was recorded in their notes for future reference. The impact of a lack of continuity on midwives’ ability to be women’s advocates was discussed by Holly. I think that it’s . a lot easier to advocate people that you know well, because I think you can if you’re a [maternity ward] midwife but you don’t necessarily know her history and you don’t know why the woman is making the decision she is, so it’s a lot harder to be able to know what that woman really wants (Holly – standard care midwife) Thus it was more difficult for standard care midwives to utilise their knowledge, skills and position to advocate for women when they did not know them and had no overall responsibility for their care. As the caseload midwives had more time to dedicate to individual women, as well as more responsibility for, and continuity with, individual women, we saw and heard of more examples of advocacy within this model of care. The caseload midwives appeared more able to utilise their knowledge of the maternity and community services, and their position as gatekeepers to those services, to pre-emptively provide care where and when it was needed. By virtue of the continuity they shared with women, and the responsibility they had for their care, they were also more able to utilise their knowledge, skills and position to help women navigate through the complex maternity system and thus avoid ‘‘falling through gaps’’ in the distributed services. People aren’t just a faceless person that you’re never going to see again. So you have to be competent, your competence levels then increase because, like I said earlier, if you’ve got a woman with something that you’ve not come across then it’s up to you to find out about it because you can’t think, oh well the next person will see, because it’s going to be you, the next person seeing her. So you’re more thorough, so you will chase up blood results, you will find a way round to find out about what is this or what services are on offer for her in the community, because it’s only going to be you seeing her next time. I think less things get missed or left (Jess – caseload midwife) This type of advocacy is addressed by Huezo and Diaz in relation to family planning. They claim that ‘‘a quality of care strategy should be more pro-active than reactive. This means that activities leading to the prevention of problems should precede activities leading to the

correction of shortfalls in quality’’ (1993:138). This was the kind of care the caseload midwives, including Jess and Sarah, were able to, and were observed to, provide. I’m looking at ... first time mums that maybe need a lot more support . mums without good English language or use of the community . mums with anything that’s identified as a known difficulty, particularly difficult social circumstances . because again you’ve got a constant, you can start beginning to trust a constant, you build up a relationship with the constant, it’s much easier to say things quicker, you haven’t got to start from scratch every time, and in some way you begin to feel someone’s rooting for you (Sarah – caseload midwife) Sarah’s final statement, that one of the benefits of caseload care for women is that ‘‘someone’s rooting for you’’, not only provides the title for this paper, but also highlights how caseload midwives can use their advocacy role to support women and help them access the best available care. Advocacy and bureaucracy Nevertheless, advocating for clients can prove disadvantageous to street-level bureaucrats when it places them in conflict with their colleagues and managers. Holly, for example, believed that in order to advocate for her client, she had to place herself in opposition to an obstetric colleague who was emphasising the importance of following hospital guidelines. Though she succeeded in advocating for the woman, by her own admission she had to ‘‘fight’’ to do so. I had a row with a registrar because my [vaginal birth after caesarean] lady declined continuous monitoring and declined to have a [canula] in . I felt quite pressured into the fact that, you know, ‘‘Well she needs to have a [Cardiotocograph], she needs to have a [canula]. She has to.’’ And it was like, ‘‘Well actually she doesn’t have to do anything, it’s her choice, she knows the risks and everything else, she’s made this decision’’... So I think in caseload you can protect your women a lot more, and then they feel a lot more empowered to do what they want themselves, because they’ve got someone fighting their corner for them (Holly – caseload midwife) This situation saw Holly utilise her position as the woman’s named midwife to secure for her the freedom to choose. Holly chose to advocate for the woman by taking on the role of her agent, promoting the woman’s interests above all else (Mechanic & Meyer, 2000:663). However, had Holly not worked under the caseload model, and thus had not had relationship continuity with the woman, nor felt such a strong obligation to the woman, she may have avoided the conflict and difficulty that came with advocating in this way. Cherie, a standard care midwife, also spoke of her attempts to advocate for women. However where Holly had come up against a colleague, for Cherie the obstacle was managerial diktat, and her method of advocacy more covert. Cherie admitted that at times she overstated concerns about the condition of a baby she sees postnatally, such as saying it is slightly jaundiced, in order to secure another visit for the woman. She does this, as booking another visit for a healthy mum and baby is likely to get her in trouble for wasting midwife time – even though they may have only been seen once (Observations with Cherie – standard care midwife) As both of these examples show, advocacy is not necessarily supported by the organisation as a whole, which is charged with providing an equitable and consistent service with scarce resources

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and standardised guidelines. Thus advocating for a client can be a difficult path for any worker to tread. However, where Holly had the support of her caseload group practice, Cherie had no such backing. Despite their greater focus on individual clients, at times caseload midwives also felt the pressure of juggling the conflicting demands of women’s needs and the needs of the system. Hence the caseload model does not guarantee that all midwives will provide a client-centred service, and it does not guarantee that they will all act as women’s advocates. Katie, for example, had specifically stated that she did not want students to take part in her care, and yet her caseload midwife constantly attempted to change her mind, and even brought a student to one appointment. Similarly, despite Daniella clearly stating that she wanted to give birth in the obstetric-led birth centre, her caseload midwife recorded the planned place of birth as the midwife-led birth centre. They ticked like ‘home-from-home’ when I was saying to them at least twenty times that I wanted doctors around at the hospital. But of course at that point I didn’t know exactly which was which ... I went on to the internet and I found out and then I was really, really upset. But I didn’t tell them because what’s the point in upsetting people who are going to be around you when you’re having your baby (Daniella – caseload care, first baby) In both cases it would seem that the midwives privileged their own beliefs regarding what was ‘‘best’’ over the woman’s choices. Thus while caseload midwives are perhaps more able, and therefore more likely, to tailor women’s care to their needs and act as their advocates, this is not guaranteed, especially when women’s choices clash with widely held professional views. Through these examples we therefore see the exercise of professional power. These midwives can be seen to be privileging their own needs (that students receive hands-on experience) and routines, or possibly professional exclusionary interests,(that low risk women go to the midwife-led birth centre), over the choices of the women they are caring for. Consequently in providing care that is more service-centred than woman-centred, and in not advocating for women’s needs, some caseload midwives show that, like many of their counterparts working in standard models of care, they too can treat women according to the routines deemed appropriate by the organisation (Prottas, 1979). Discussion The tensions within the role of street-level bureaucrats are complex. Lipsky contends that, although street-level bureaucrats attempt to do a good job, the job ‘‘is in a sense impossible to do in ideal terms. How is the job to be accomplished with inadequate resources, few controls, indeterminate objectives, and discouraging circumstances?’’ (1980:82). Nevertheless, while Lipsky’s theory is useful in understanding the challenges facing street-level bureaucrats, his argument that ‘‘the very nature of this work prevents them from coming even close to the ideal conception of their jobs’’ (1980:xii) seems unnecessarily fatalistic. Contrarily, we contend that the people-processing nature of the current health system is not inevitable. As Allen et al. write, ‘‘social structures and constraints do not exist in some reified form, they have to be enacted’’ (2004:416). Thus it is through street-level bureaucrats’ accounts of their actions and their sense-making activities that they frame organisational structures as real and constraining. We therefore propose that Lipsky’s assertion that the job of a street-level bureaucrat is impossible to do in an ideal way is not necessarily, nor completely, true. It may seem impossible within fragmented care models where workers hold no overall responsibility for the clients they care for,

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have little control over the organisation of their work, work within organisations that prioritises their own needs over those of clients’ and are unable to be advocates. Yet, as Lipsky himself asserts models of practice can be reconstructed in a less-bureaucratic manner. Nevertheless, Lipsky struggled to identify any way in which to reconstruct the public services so that they are both more clientcentred and more likely to produce effective service-providers. The reason for his struggle was that he saw the need for extensive social and political change at a macro level. Change, he believed, could only be translated into the world of street-level bureaucracies with the support of managers, street-level bureaucrats and clients, a coalition he viewed as unlikely to form. However in the contemporary context of UK maternity care specifically, and healthcare broadly, where such coalitions and collaborations are encouraged by government initiatives (e.g. Department of Health, 2008b), models of care that offer relationship continuity, and focus on the experience and journey of service users through a system, may provide a way forward. For it would seem that altering the model of street-level bureaucrats’ practice, so that it centres on the provision of continuity, begins to reconstruct the nature of their work in the ways desired. Such redesign arguably better equips workers to prioritise client’s needs, take responsibility for their care, and advocate for them. In the light of these positive outcomes of the caseload model of care, questions remain. From our interview and observation data, it became clear that the caseload model increased the likelihood that midwives would advocate for individual women. We posit that the midwives’ increased personal obligation and their increased ability to exercise discretion were both factors associated with this increased advocacy. However, as we were focused more on the provision of advocacy than the reasoning behind it, this issue requires further, focused investigation. Likewise it became clear that the women cared for under, and the midwives who worked within, the caseload model of care generally had more positive experiences and relationships with each other than their counterparts in the standard model of care. Therefore at a micro level, caseload care appears to be beneficial. However, further understanding is needed of the impact at a health system level. Potentially, without the personal obligation to individual clients, standard care midwives are better able to prioritise the macro concerns of the system, such as organisational efficiency, and the need to equitably distribute limited resources among a large population of clients. While this is in line with old style universalist NHS bureaucracy, the NHS has now committed to a new ‘‘progressive universalism’’ (Department of Health, 2008a). Progressive universalism aims to provide ‘‘a universal service that is offered to all families with additional services for those with specific needs and risks’’ (Department of Health, 2008a:11). Therefore, while standard care midwives may be better able to prioritise the equitable distribution of resources, due to their lack of continuity with women, they may simultaneously be less able to assess and monitor individuals’ needs and risks. The ability to assess individuals’ needs is not only a prerequisite for the provision of progressive universalism, but also for the fulfilment of midwives’ professional obligation to provide women with advocacy (Nursing and Midwifery Council, 2008). Midwives however work within an organisation where advocating for individuals is not necessarily consistent with the organisations’ needs. Thus when their professional and organisational obligations come into conflict, as they did for both Holly and Cherie, midwives can find themselves ‘‘stuck in the middle’’. Subsequently, despite potential benefits for street-level bureaucrats and their clients, models of practice that centre on

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continuity may have unintended consequences for both the streetlevel bureaucrats themselves and the street-level bureaucracies charged with providing equitable services with limited resources. There may also be other potential problems with implementing new service models centred on continuity. For example, at an organisational level health systems are generally resistant to such different ways of thinking (Davis-Floyd, 2001). From a workforce perspective, they require the commitment of workers who are also resistant to change, and bear potential complexities in terms of managing work-life balance (Sandall, 1998). While at a client level, such new service models may not be appropriate or desired by all women (Freeman et al., 2007). None of the women we spoke to expressed a desire for less continuity. However given the difficulties of determining what women want from maternity services (DeVries, Salvesen, Wiegers, & Williams, 2001), it is important to design future service models that allow women to change their caseload midwife, or opt-out of caseload care, if they wish to do so. The existence of potential problems does not however imply that attempts to implement models of care centred on the provision of continuity should be abandoned. Rather it highlights that implementing such changes, while beneficial in many ways, may not be easy or without inadvertent repercussions. Furthermore they may require strategic support at a system level. Conclusion In this paper we have drawn on theories of street-level bureaucracy in an attempt to understand how midwives working on the frontline within two different care models, manage the competing demands of providing women with a personalised service and advocacy, while working within a bureaucratic work organisation. The conclusions that can be drawn from this study are, however, limited to the site under investigation. Furthermore as this model of care was new, further work on the sustainability of the model is important. Nevertheless, we have shone some light on how a caseload care model can shift midwives’ allegiance from the organisation for which they work to the women for whom they care, with positive outcomes for both the midwives and the women. Thus, where other authors investigating street-level bureaucrats have primarily focused on the impacts of detrimental models of working, we provide a case study of how an innovative model, centred on the provision of relationship continuity, can benefit both these frontline healthcare providers and their clients. However, such a model of care is neither easy to implement nor comes without potential unintended consequences. References Allen, D., Griffiths, L., & Lyne, P. (2004). Accommodating health and social care needs: routine resource allocation in stroke rehabilitation. Sociology of Health and Illness, 26(4), 411–432. Armstrong, D. (1985). Space and time in British general practice. Social Science & Medicine, 20(7), 659–666. Bramesfeld, A., Klippel, U., Seidel, G., Schwartz, F., & Dierks, M. (2007). How do patients expect the mental health service system to act? Testing the WHO responsiveness concept for its appropriateness in mental health care. Social Science & Medicine, 65, 880–889. Brodkin, E. (2001). Accountability in street-level bureaucracies: issues in the analysis of organizational practice. Paper presented at the 5th International Research Symposium on Public Management, Centre d’Iniciatives de L’Economia Social, University of Barcelona, Barcelona, Spain, April 9–11, 2001. Checkland, K. (2004). National Service Frameworks and UK general practitioners: street-level bureaucrats at work? Sociology of Health and Illness, 26(7), 951–975. Davey, M., Brown, S., & Bruinsma, F. (2005). What is it about antenatal continuity of caregiver that matters to women? Birth, 32(4), 262–271. Davis-Floyd, R. (2001). The technocratic, humanistic and holistic paradigms of childbirth. International Journal of Gynecology and Obstetrics, 75(Suppl. 1), 5–23. Department of Health. (1993). Changing childbirth. Report of the expert maternity group part 1. The Cumberlege report. London: Her Majesty’s Stationary Office.

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