ALSO UK 20 years on: Reflections, challenges and lessons learnt


ALSO UK 20 years on: Reflections, challenges and lessons learnt What better way to reflect on our achievements than to seek out and explore the initial ideas, concepts, conditions and developments that have led to where we are now—an approach used by those seeking insight and answers through reflection. Our story begins in the rural farms and forests of Wisconsin, the 30th state of the USA, with borders on the Great Lakes of Michigan and Superior in the midwest of America. Like many other parts of the world, large urban communities compete with their rural neighbours for resources and health care, and it is often the latter that struggles to meet the necessities of wealth, health and wellbeing. Necessity is, nonetheless, ‘the mother of invention’; the need that drove the initial idea of developing an advanced course in obstetrics was the falling number of family physicians providing maternity care in rural and underserved parts of Wisconsin (Damos and Beasley, 1996). This was a situation not dissimilar to the increasing loss of GP involvement in maternity care in the UK during the 1990s. Maternity care continues to be a key stage of the family life cycle and two family physicians, Dr James Damos and Dr John Beasley—both of whom had a wealth of experience in rural family medicine— joined forces to develop a curriculum that would assist and enhance other family doctors to safely and effectively respond to maternity care emergencies. So began the programme of Advanced Life Support in Obstetrics (ALSO), which was initially administered under the auspices of the Department of Family Medicine at the University of Wisconsin. Further developments to the course were based on similar lines and techniques used by other nationally recognised life support courses and, with the help and involvement of likeminded colleagues, the first ALSO (USA) course was held in Madison, Wisconsin in September 1991. The popularity and demand for the ALSO provider programme soon outstripped the resources and teaching staff available through the University of Wisconsin(Beasley et al, 1994: 1037):

‘Between 1991 and 1993, a total of 1315 doctors and nurse midwives attended 35 ALSO courses. Seventy-six percent were family physicians in practice and twenty percent were from rural communities. About fifteen percent were from hospitals with no obstetric or paediatric staff available. Attendees reported a significant increase in their level of comfort in the management of obstetric emergencies and a greater intention to continue practice in maternity care.’

Consequent to this, an instructor’s course was developed and first delivered in San Diego, California in April 1993. High-scoring individuals who successfully completed all elements of a provider programme—along with meeting the standards of effective team working and good communication, and upholding the ALSO philosophy of care—were invited to undertake an instructor programme. This led to a significant and geographically diverse number of potential instructors available to teach on ALSO programmes across the USA. In June 1993, the ALSO programme was transferred from the University of Wisconsin to the American Academy of Family Physicians (AAFP), and its success continued unabated. In early 1996, with the publication of the third edition of the ALSO Manual, more than 7000 participants had completed an ALSO provider course, which had been held across the USA and Canada, as well as on US military bases overseas (Damos and Beasley, 1996). Publicity at conferences, medical meetings and publications (Beasley et al, 1993; 1994), led to a wider international interest in the value and benefits of the ALSO course. The UK, Pakistan, Russia and the Netherlands were some of the countries that expressed interest in the provider programme, and the possibilities that ALSO would become an international programme were soon realised (Damos and Beasley, 1996). The principal reasons for this were clearly articulated in the work of Beasley et al (1994: 1037):

‘Unexpected emergencies occur during routine maternity care. Perceived or actual deficiencies in training may decrease the quality of care and increase liability risks and anxiety among providers. This may lead the provider to discontinue obstetrics, which results in problems in access to care. To improve the training for obstetric emergency management, an Advanced Life Support in Obstetrics (ALSO) course was developed. This skillenhancing course, modeled after other life support courses, is designed to improve the quality and availability of maternity care through standardised training in the management of emergencies and improved communication between maternity care providers.’ 

The transatlantic crossing of ALSO to the UK came about incidentally. In 1994, while on holiday in the USA, a British GP, Dr Jim Kennedy, heard about the success and possibilities of the ALSO programme. The provision and delivery of maternity care in the UK was in significant flux following the publication of the Changing Childbirth report (Department of Health, 1993) and, with great enthusiasm, Dr Kennedy believed it was an opportune time to introduce ALSO into the NHS. Initially, he sought funding from the Changing Childbirth Implementation Team (CCIT) on the basis that the course would benefit GPs, but given the CCIT’s clear aspirations for multi-professional education and working, the application was rejected with suitable advice given. Not one to give up, Dr Kennedy got together with obstetricians, GPs and midwives in the North of England and a further application was made with a clear commitment to multi-professional education and training—a seminal principle, which has underpinned all ALSO UK teaching, courses and teamwork. This time, the application passed muster and a generous grant from the CCIT enabled a small team of midwives and doctors to visit the USA and undertake an ALSO provider and subsequent instructor course. Suitably prepared and wanting to push ahead, the first ALSO UK provider programme took place in Durham, in June 1996. A further course was run in quick succession and, before the year was out, ALSO UK had delivered its first instructor course, paving the way for provider and instructor courses to be delivered throughout the UK and the Republic of Ireland. ALSO UK continued to work closely with colleagues on the ALSO USA Advisory Board, and we officially signed our first license agreement with the AAFP in 1997. A subsequent extension agreement signed in 2002 enabled an ongoing annual renewal of our license. It seems like only yesterday that I sent of my application to undertake the first UK ALSO course (Lewis, 1996a). The same is true of my co-authors and, while we all wonder where the time has gone, there are no doubts about the benefits we have gained from being a part of such a dynamic, collegiate and supportive teaching faculty. ALSO UK was a gift and it keeps on giving. While at the outset we fully understood the aims and objective of the programme, we were less sure of its true nature and what impact it would have on our professional lives and careers. To be honest, we were pleasantly surprised by the absence of hierarchy in the teaching faculty, and somewhat overwhelmed by the shared enthusiasm in nurturing and improving our skills, decision-making abilities and developing positive, inter-professional working relationships (Lewis, 1996b). While we were taught—and continue to teach—the ALSO way, it is recognised that this is not the only way; there are many approaches to dealing with the wide and variable conditions that are classified as obstetric urgencies or emergencies. However, this emphasis on the ALSO way is underpinned with equally clear and directed instructions that ‘all healthcare professionals need to take their learning, regardless of who or where it is taught, and apply it in a way that acknowledges and addresses the context of care, the needs of the woman and her family and the environment in which they find themselves’ (Lewis, 2014: 391). It is also through such variable situations and our sharing of experiences that we reap the greatest benefit from the personal insights, discourse and deliberations of our respective colleagues and co-workers from different professional backgrounds. ALSO UK’s initial programme has changed over the years, with less of an emphasis on lectures, and a greater focus on case-discussion and problem-solving. In our workstations, a mnemonic-based approach is still applied where it is relevant, and direct hands-on skills training is expected of all candidates who are continually assessed throughout the 2 days of the provider course. The academic assessment process continues to use a multiple-choice questionnaire, which covers a broad range of antenatal, intrapartum and postnatal issues related to obstetrics and medical complications, urgencies and emergencies, although these have changed over time to reflect new ideas and priorities. The practice element of the course, which is called a Megadelivery but in truth is a ‘serial disaster station’, can be extremely challenging but worthwhile; for many midwives, this may be the first occasion since qualifying that their practice skills are objectively assessed. Prior to, throughout and at the end of each course, issues pertaining to the quality of the programme and teaching are constantly reviewed. Candidates who achieve high scores in their workstations and demonstrate the attributes of excellent team working, as well as passing their academic and practical assessments at the first attempt, are selected as potential instructor candidates and invited to undertake an ALSO instructor course. Quality assurance of the programme is paramount and instructor candidates are required to teach and pass assessment on two subsequent provider programmes before they become fully fledged ALSO instructors. Faculty reviews before and after every ALSO providers course ensure consistency and quality of teaching, and explore any issues arising or feedback from candidates, which enables the Advisory Faculty and ALSO Executive Board of Trustees to alter and improve the programme as needed. Over the last 20 years, ALSO UK has educated and trained over 18000 midwives and 6000 doctors, as well as many other health professionals involved in the provision of maternity services. Important among these are paramedics, who undertake a 1-day essential life support course (ELSO), which addresses pre-hospital maternity needs and the management of obstetric emergencies. Looking back over the last 20 years, we can see how ALSO UK has made a significant impact on the way midwives and medical colleagues work together. It has enabled a more open, frank and friendly discussion as to what we do and how we do it, while ensuring that the needs of women and babies remain central to our teaching, learning and ongoing working relationships. It is our belief that the greatest benefit of the ALSO UK course is its ability to break down interprofessional barriers and allow people to share their ideas, practice and concepts outside of their own working environments—to learn in a safe but challenging environment, and to understand the unique contributions we bring as midwives, obstetricians and other 4 British Journal of Midwifery • June 2016 • Vol 24, No 6 comment © 2016 MA Healthcare Ltd health professionals to the care of women throughout pregnancy and childbirth. The patient safety consequences of never stepping outside of your own working practices have been clearly demonstrated in recent, devastating reports (Francis, 2013; Kirkup, 2015); together, we need to find ways to ensure such failures are avoided in the future. At times, all of us will face challenges to the ways in which we work, our professional beliefs and how we apply our knowledge and skills in our respective roles as maternity care practitioners. This is not easy to accept, but all of us must be prepared to recognise when time, evidence and practice have moved on. We need to constantly review what we do and how we do it—refining, rejecting or learning new approaches to care and new ways of working together. This has been paramount in the approach that ALSO UK has taken in planning and developing its current courses with new, modified and expanded skills and drills stations that still challenge our candidates, but also consider the changing nature of practice, new research evidence and the expectations and needs of the women and families in our care. ALSO UK is using national review data such as the MBRRACE reports, with their focus on lessons learnt, to inform both perinatal and maternity care (Knight et al, 2015); this has provided an added impetus that drives our contextbased learning both in the theory and practical aspects of our course. ALSO is unique in many ways and continues to explore the association between high-quality care and patient safety. We must ensure that, ultimately, our teaching systems keep mothers and babies safe, and that midwives and obstetricians remain confident and competent in their provision of care—even more so when rare but life-threatening events occur. Teaching alone is not enough, and what 20 years of ALSO UK has taught us is that the skills, knowledge, capability and competence of maternity care practitioners must be assessed in a supportive, independent environment, in which a model of collegiate, collaborative interprofessional working is clearly evident. The challenges and changes to our working lives will not disappear, and neither will the expectations of those we serve. If we are to meet these demands and deal with them in a helpful, holistic and healthy way, we need to do it together using our shared experiences and expertise. This has been the mantra and mindset of ALSO UK over the last 20 years, and we would like to thank the multitude of midwives, obstetricians, GPs and other health professionals, candidates and students who, along with our fantastic administrative team, have undoubtedly contributed to our success.

BJM Beasley JW, Byrd JE, Damos JR, Roberts RG, Koller WS (1993) Advanced life support in obstetrics course. Am Fam Physician 47(3): 579–80 Beasley JW, Damos JR, Roberts RG, Nesbitt TS (1994) The advanced life support in obstetrics course. A national program to enhance obstetric emergency skills and to support maternity care practice. Arch Fam Med 3(12): 1037–41 Damos JR, Beasley JW, (1996) The History of the “Advanced Life Support in Obstetrics” Program. In: ALSO Manual. 3rd edn. American Academy of Family Physicians, Leawood, KS: 9–10 Department of Health (1993) Changing Childbirth. Part 1: Report of the Expert Maternity Group. DH, London Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. The Stationery Office, London Kirkup B (2015) The Report of the Morecambe Bay Investigation. The Stationery Office, London Knight M, Tuffnell D, Kenyon S, Shakespeare J, Gray R, Kurinczuk JJ, eds. (2015) Saving Lives, Improving Mothers’ Care: Surveillance of maternal deaths in the UK 2011–13 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–13. National Perinatal Epidemiology Unit, Oxford Lewis P (1996a) The Advanced Life Support in Obstetrics Course. Modern Midwife 6(12): 17–19 Lewis P (1996b) Advanced Life Support in Obstetrics — A course with a difference. Changing Childbirth Newsletter October(7): 10 Lewis P (2014) Discourse on dystocia: A much needed professional dialogue. British Journal of Midwifery 22(6): 390–2. doi: 10.12968/ bjom.2014.22.6.390

Paul Lewis OBE Emeritus professor of midwifery practice, Bournemouth University

Alison Collier Senior midwife, William Harvey Hospital

Ciaran Crowe National Medical Director’s Clinical Fellow

British Journal of Midwifery • June 2016 • Vol 24, No 6 3 comment © 2016 MA Healthcare Ltd

August 8, 2016