There has been a lot of conversations across social media and various fora about caseload midwifery and working towards a continuity of carer model. There is a lot of anxiety and myth, misperceptions and unfounded concerns. I have had the pleasure to work across various systems in the UK and overseas. In the UK I worked in a group practice, standard maternity care and as an independent midwife. The standard fragmented care in which primary and secondary services are separately staffed simply did not resonate with me. The group practice arrangements I worked in at Chelsea and Westminster hospital in the 90s, although fun at the start, also were frustrating and exhausted me. Working independently in the UK was wonderful yet very stressful at times due to not being fully integrated into the system and the need to ask for payment. When I worked in New Zealand it was a fully integrated system in which women booked a midwife directly without having to pay when they were a resident or citizen. I have described the NZ system elsewhere. 
I am not going to re-state the supporting research evidence for caseloading, you can find that elsewhere. What I want to do here is first describe what continuity of carer is for me. It is being the main point of contact for a women through pregnancy, labour and birth then postnatal. Care is only handed to others when I am on holiday, weekends off, sick, study days or have two women go into labour at the same time! The care I provide traverses risk and chosen location for birth. I follow the women where she intends to birth. The arrangement is flexible and agreed in partnership at each step of the journey.

For caseloading to work I needed:

• Excellent support structure with colleagues
• Like minded colleagues who were philosophically aligned
• Fair remuneration for the work I did that was equitable and matched the level of skill. Payment to be organised through ministry of health and be free at point of delivery to women.
• Regular time off arranged with practice partner.
• Self determine my ways of working, e.g. When to do clinics, postnatal visits, Case load numbers, organising annual leave and weekends off call in liaison with practice partner.
• One full month off for AL per year in one go, plus another week decided amongst group practice.
• Partnership working with women that was reciprocally sensitive to each other’s needs
• Time to be off call when needed urgently.
• Generosity of spirt and good communications amongst colleagues
• Excellent relationships at interface with hospital colleagues (midwives and medical)
• Regular support and guidance from the midwifery council and college of midwives
• Understanding family who supported my way of working
• Great rapport with everyone in my local community where I was working
• Reliable car and phone!

Background

Caseload 4-6 per month. Reasonable living wage that was slightly more than colleagues working shift work in the hospital. The payment for caseload midwives in NZ is presently being challenged to meet inflation and degree of responsibility. At the time of this diary entry the 4-6/month booked women provided an adequate pay yet this had not increased with inflation hence current challenge.
I worked with 8 other caseload midwives split into partnerships for weekend off call, holidays, SDs, sick, 2nd midwife for primary births and when need support for long labours or when two women go into labour at the same time! Clinic times and postnatal visit times decided by myself and confirmed with women as needed. Key is flexibility. Some midwives prefer to do all clinics in one day, all bookings another day for example. Partnership is essential between the women and myself as well as with practice partner, group practice and associated support services such as GPs, primary birth unit staff and local hospital colleagues.
So what did a month look like? Was I over worked? Was being on call a constant intrusion in my life? Did women abuse the on call system and call me constantly?

Here is one month activity from my practice diary. All names and places have been removed. Each month was different but this gives you a snap shot.
So here it is…   

Week one

Monday. On call, Antenatal clinic 8-12noon (8 women). Postnatal visits x3 X1 booking (2 hours). Home by 430pm. No calls

Tuesday on call x4 Post natal visits in morning. Office admin work afternoon. No calls.

Wednesday on call 3 post natal visits in morning. Afternoon free. No calls.

Thursday on call antenatal clinic (8 women). X2 PN visits. Practice meeting cancelled everyone busy. Home at 3pm. Called at 10pm to a birth. Home at 8am Friday morning.

Friday on call. Morning free to sleep. X4 postnatal visits in afternoon. Home by 5pm. Practice partner took my on call 6-11pm so I could go out of area to an event.

Saturday, on call, no calls. X1 PN visit.

Sunday, on call, no calls. X1 PN visit.

(Total hours actually away from home and working = approx 36 hours)

Called out outside of Monday to Friday working days – once
Week two.

Monday on call. Antenatal clinic 8-12. PN visits x4. Home 4pm

Tuesday on call. X1 booking 9-11am. X3 postnatal visits. Home 2pm. No calls

Wednesday on call. No calls, no visits. Admin catch up (2 hours)

Thursday on call. Antenatal clinic 8-12. Practice meeting over lunch. X 4 PN visits. Home by 4pm. Took practice partners on call so she could have an evening off.

Friday called to birth at 7am. Home at 1pm. Booking 3-5pm. Called to be 2nd midwife at birth 7-11pm.

Saturday on call for my own case load and practice partner for her weekend off. X1 PN visit no calls

Sunday x2 PN visits. Free by lunchtime. Called at 5pm for BF problem.
(Total hours approx 35 hours away from home + 1-2 hours phone and admin work)

Called out or working outside working Monday to Friday working hours – twice
Week three.

Monday on call. Antenatal clinic 8-12. PN visits x4. X1 booking. Home at 5pm.

Tuesday on call PN visits x2. Free from 11am. No calls

Wednesday. Called to induction of labour at 11am (post dates). Home at 11.30pm.

Thursday on call Antenatal clinic 8-11am. X 3 PN visits. Practice meeting over lunch. Home by 3pm. No calls.

Friday on call PN visits x4. Booking 1-3. Hand over on call to practice partner at 6pm.

Saturday and Sunday off call.
(Total hours approx away from home 38 + 1-2 hours phone and admin work)

Called out or working outside working Monday to Friday working hours – once
Week four

Monday on call from 8am. Antenatal clinic 8-12. PN visits x4. Called to birth at 4pm, home at 9pm.

Tuesday. Called to be birth support for practice partner at home birth 7-11am. X3 PN visits. Booking visit 3-5pm. No calls.

Wednesday. No calls all day. Did 2 hours of admin.

Thursday Antenatal clinic 8-12. Practice meeting over lunch 12-2pm. Then X2 PN visits. 

Friday x3 PN. Visits. X1 booking. Perinatal mortality meeting at local hospital 1-3pm

On call from 6pm for practice partner also for weekend.

Saturday called to birth at 6am (practice partners caseload). Home by 4pm.

Sunday X1 PN visit. No other calls.
(Total hours approx working away from home 35 hours + 1-2 hours phone and admin work)
Called out outside working Monday to Friday working hours – twice
I for one flourished and loved this way of working. The rewards that I derived from the relational model of care continue to resonate throughout my perspectives on midwifery. The relationships energised and inspired me. Yes at times I was tired and wanted to ‘just turn off my phone’ yet these times were frequently ‘healed’ by the next encounter, the next birth, the next moment of awe; that as midwives we have the privilege to be invited to.
Don’t let caseloading and continuity of carer worry you or cause anxiety. It has been a wonderful part of my work as a midwife which I often miss now embedded in academia. The joys of working that way always outstripped the moments of vulnerability. Providing advice and care to women and seeing and hearing first hand how it worked or did not work so well for them shapes practice decision making. Meeting up with women again and again over the years whilst they make their families is a joy. 
I would say it was being a caseloading midwife that really highlighted the art and magic of midwifery in ways that will always be dear to my heart. Don’t be afraid of caseloading, it’s sustainable, enjoyable and doable with the right support and flexibility. I know colleagues who are still flourishing after 20 years working this way, colleagues with young children, colleagues who just qualified and colleagues who had never worked in the community prior to caseloading. The barriers to this way of working can be overcome with the support, desire and inspiration to succeed.
What do others think? Would this work in the Uk? Would this work as a national approach for Scotland for example? Do you have your own experiences?
Go well