Wild Card - Whose Shoes?

46. Rosie Murphy - addressing health inequalities in maternity

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Rosie Murphy is a midwife doing fantastic work around health inequalities, including the coproduction workshop we co-led in Croydon.

Our conversation builds on Episode 45 with Noreen Bukhari. I hope Rosie and Noreen will connect and exchange notes on their excellent work in Coventry and Croydon, supporting women from black and ethnic minority communities.

I met and became friends with Rosie through her prestigious Darzi fellowship – Rosie's work was rated as exceptional.

Lemon lightbulbs  🍋💡🍋

  • Racism is not just about shouting expletives - it is complex
  • We all have unconscious bias
  • There is unwillingness to acknowledge systemic racism
  • UK institutions are largely built around the needs and understandings of white middle class men
  • We need to be culturally aware to understand what matters to people
  • Whose Shoes uses imaginative ways to listen to ALL voices
  • Trust, being listened to, being taken seriously MATTER
  • Education, socio-economic status, ethnicity, body, size affect how likely to be taken seriously
  • There is mistrust and distrust of the NHS/ maternity services among some groups
  • Maternity services are difficult to navigate!
  • The NHS doesn’t need to fix all problems itself
  • Use informal communication channels that people trust - hairdressers!
  • Social deprivation has many impacts – services need to flex more
  • White allyship includes owning our own biases
  • Call people in, not call them out
  • Lived and learned experience - work TOGETHER for safety of mother and baby
  • Women who've had a negative experience find it harder to speak out next time
  • HEARD campaign, Croydon – Health, Equity And Racial Disparity
  • Find simple ways to show women they are being taken seriously
  • Creative ways for people to feedback
  • Croydon BME Forum / Asian Resource Centre reach people in imaginative ways - eg community healthcare drop-in session
  • Share the learning eg infographics, blogs, Steller Stories , Sway reports
  • Connect and learn from others

Links and resources

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Please recommend 'Wild Card - Whose Shoes' to others who enjoy hearing passionate people talk about their experiences of improving health care.

 

Rosie Murphy

Sun, Feb 12, 2023 7:50PM • 1:06:51

SUMMARY KEYWORDS

people, nhs, maternity services, croydon, women, absolutely, maternity, fellowship, talking, podcast, rosie, assumptions, racism, terms, felt, hospital, concerns, inequalities, trust, appointments

SPEAKERS

Gill Phillips, Rosie Murphy

Gill Phillips  00:11

My name is Gill Phillips and I'm the creator of Whose Shoes a popular approach to co-production. I was named as an HSJ 100 Wild Card and want to help give a voice to others talking about their ideas and experiences. I'll be chatting with people from all sorts of different perspectives, walking in their shoes. If you are interested in the future of health care, and like to hear what other people think, or perhaps even contribute at some point, 'Whose Shoes - Wild Card' is for you.

Gill Phillips  00:46

Hello, and welcome to today's podcast, where I am super excited to be talking to my friend, Rosie Murphy, a young midwife who is punching way above her weight and doing some truly fantastic work around health inequalities, including the co-production workshop that we led together in Croydon. I'm sure our conversation today will build perfectly on my most recent podcast where I spoke to Noreen Bukhari. I'm really hoping Rosie and Noreen will strike up a huge connection through this podcast series. If you haven't heard it, please do check out the episode with Noreen who talked about the extraordinary work supporting women from Black and ethnic minority communities in Coventry, which has been running for many years. And by connecting Rosie and Noreen, I hope we can connect the work in Coventry and Croydon, two very interesting places. And I think in some ways with similar challenges. They're certainly similar in that both localities are keen to care about people and promote inclusion. I met Rosie through her Darzi fellowship. Rosie is one of the Darzi 13 cohort, so has recently finished her project, which was rated as exceptional. So being as the Darzi Fellowship is such a prestigious programme. I hope you're extremely proud of that. Rosie, and never mention Impostor Syndrome again. So welcome, Rosie. We will have to be very focused, as I know we can literally talk for hours - and have done many times. Where would you like to start? Perhaps tell us a little bit more about yourself.

Rosie Murphy  02:28

Oh, thank you so much, Gill, that's such a wonderful introduction. And I have to say, it brings me such joy that you described me as young as well. 

Gill Phillips  02:38

Well, you are to me! Where would like to start?

Rosie Murphy  02:41

I think one of the things that would be useful to discuss is perhaps a little bit about how I got to doing the Darzi fellowship, because I think that I've taken a slightly unorthodox route in midwifery. And certainly, if you'd have asked me when I was a student, or newly qualified midwife, where did I see myself now? I'm not sure it would have been here. So I qualified as a midwife 13 years ago, and I am so passionate about midwifery. And I went into it when I was straight out of school. And I think that it's difficult to understand exactly what drove you at that point. But I look back on it now and I think it's always wanting to be a passionate advocate of women's rights, and also recognising the way in which family life is really the bedrock of society. So wanting to give mums the best start on their journey into motherhood. But I think it's also fair to say that I, from very early on, often found the system quite frustrating, and rubbed up against it, even as a student. So I think as a student, I always knew that I wanted to be a practising midwife, and a change agent. But I certainly wouldn't have known in those days exactly how do you go about that? One of the ways in which I think I could identify, even as a student, that you could bring about change was through clinical research. And I was very lucky to get a National Institute of Health Research scholarship to do a Master's in clinical research. And that was thoroughly enjoyable. And I really recommend it. But I think probably at that stage, that was the way I was going to take my career - it was going to be clinical academic. And that's quite a well defined pathway. But my experience of how easy it was to stay on that pathway after I had my own children was ... well, it wasn't easy at all. And I think therefore it left me casting around a bit as a midwife for what other opportunities are there?  How else could I drive change? And probably health inequalities, but certainly race-based inequality has been something that I've been very passionate about, even from school. I think it's terrible that my entry into understanding about race and ethnicity and inequality was through studying the American Civil Rights Movement, and that there's no teaching about our black British history. But nonetheless, like so many people, that was what first opened my eyes to, I think, the social injustice of it. And so then, in the pandemic, I was managing a telephone triage service, and I saw this Darzi fellowship come up. And I'm not too shy to admit that I'd never heard of the Darzi fellowship when I saw it. So it was really the subject matter, tackling perinatal inequalities in Croydon that captivated my interest. And it was only after I then applied for it and had been offered it that I realised how prestigious and highly thought of the Darzi award is. 

Gill Phillips  06:20

Oh wow!

Rosie Murphy  06:22

So then I felt very much like I'd crept in the back door. So that was I think, how I got to the Darzi fellowship, it was a subject that like I said, my my interest in it had started right back when I was at school, but I was very aware of the the MBRRACE reports and for how long we have been reporting the disparity in maternal mortality. And I actually felt it was a huge source of shame, professional shame for me in maternity that we knew this, and there didn't seem to really be any overarching ambition about it. And that's now very much changed. But I think that lots of people said to me, even during the Darzi fellowship, "oh well, we didn't know about it then". But actually even CMACE, the precursor to MBRRACE, were reporting disparities, for example of women from different ethnic backgrounds and from different indices of multiple deprivation now, but in in those days, I think it was about different socio-economic status indicators, and the disparity of mortality. So we have known about this in maternity for quite some time. And I think that there's sort of been a bit of a shrug of, "oh, that's a shame", but never ... never really a sense that equality or inequality was the NHS's job to address. And I very much think of our role in tackling inequalities as sort of over extending the reach of your service to bridge that gap. But I think that 10 years ago, the NHS didn't see there was a need to over extend its reach. You know, it was all about a universal offer. 

Gill Phillips  08:06

That's so interesting. It just feels as if your Darzi fellowship was just meant to be and really timely. And I think for you to have explained that background, Rosie ... I've learned a lot there. And you know, how systems can make excuses in terms of "we didn't know". Well, now we do know, don't we?

Rosie Murphy  08:27

Yeah, and I think that there was mutterings about it, there was a recognition of ... that it was a problem. And I suppose the emergence of a sense that it was our responsibility to address this. But even then, what I noticed a lot was a sort of unwillingness or a fear of really naming the problem. For a long time, I would hear  other healthcare professionals talk about the disparity in maternal mortality as sort of the intersection of socio-economic status, or deprivation, and medical co-morbidities. So for example, that black women are at increased risk of pre-eclampsia or South Asian women at increased risk of gestational diabetes, and how that intersects with deprivation. And that's, that's the sole contributor, you know, that it's those two things, and that's it. And, and I think an unwillingness to acknowledge systemic racism is a thing and it's real, and it is playing a part in this too. And I think that probably even when I started the Darzi fellowship, I was still encountering that, that sort of unwillingness to acknowledge racism as a factor here. And I think that that links quite neatly into ... I noticed with the publication of my blog series, which I'm sure we can put a link to in the notes under the podcast, that one of the little quotes they'd taken out of the article and put as part of the picture was "there remains a widespread misunderstanding of how racism plays out in health care". And I think that that's quite important to name, which is that when we, as white people, think about what racism is, we think about it as shouting expletive verbal abuse at somebody in the street or the supermarket. But actually, that's one domain of racism. And that's, although I understand it's risen again, over the last few years, that that's a small part of racism, that there is another structural part of racism, which isn't operating at the conscious level, it's not somebody deciding to do that. It's about the way systems and structures are built, and how that feeds into racism. Because, ultimately, so much of the institutions of this country are based around the needs and the ideas and the preferences and the understandings of the world of white middle class men. And therefore, if you're not a white middle class, man, the way in which the system can meet your needs, is likely to be less. And I think that there's so much about Whose Shoes that is so brilliant at that, because it's helping people to understand that the system can flex, and that the system can meet these people's needs better, but we must acknowledge that there's more than one perspective. And that's the beauty of of the Whose Shoes approach that you've got all of those people around the table. And that all of their opinions are equally important.

Gill Phillips  11:56

That's really interesting. Yeah, thanks for saying that, Rosie. And I think we're all learning about unconscious bias and micro aggressions, and you know, some of these phrases that I honestly hadn't heard of until the last few years. And I know when we did our virtual series during the pandemic, and we included a session around people disproportionately affected by the pandemic, and we were trying to, especially in the early days of Zoom, and when people were in lockdown, and so on, it was about June 2020, we were doing this session, and trying to plan it so carefully so that you left people, ideally in a better place, and certainly not in a worse place. And we worked with a team of friends really from Black and ethnic minority communities to try and place it right in a helpful way. And we ended up with 'micro first steps of support'. So you know, what kind of things in a day-to-day way can we all do to help when we notice something, and to make it realistic so that we're not all going to be the person who's got the confidence or whatever it might take to be the one that stands up and calls everything out? So to pledge to do that might not be realistic, but what can you do day-to-day to push things so that things are better really? 

Rosie Murphy  13:19

Yeah. And as you were saying that, I was thinking of an experience I had a while back, linking back to the MBRRACE report, I think the point at which I noticed that suddenly that disparity of maternal mortality got traction was, slightly alarmingly, for what is a quite well educated workforce, was the first time they decided to produce that in an infographic ...

Gill Phillips  13:45

Right ...

Rosie Murphy  13:45

Which I think could open a whole other can of worms about conversations that we've certainly had in the past about effective dissemination of information. But this infographic just really struck a chord with people. All of a sudden, it had moved from it being ... not buried in the text, but being in the text and this sort of shrugged response or perhaps it wasn't such a shrug. Perhaps I perceived it as a shrug. But actually, it was just that the message hadn't really hit home. But in 2018, they produced it as an infographic. And that suddenly got a bit of traction. But a couple of years before that, I had the unfortuna  te task ... just as I'd found out I was pregnant with my second child, of writing the maternal death guideline. 

Gill Phillips  14:34

Goodness ...

Rosie Murphy  14:35

I was doing it with somebody else. In this guideline, was talking about ... if a maternal death had occurred, presenting for the family, and in ... the colleague I was working with as a nurse, and had obviously had experience with this in a way that I had never had an experience of it. And she automatically went to say, "brush the hair, so it's neat, and trim the nails". And I just wanted to say, "Well hang on a minute. Nails are a huge part of people's identity. Some people like really long, really colourful nails and, and brushing hair, I wouldn't necessarily know how to prepare somebody's hair in a way that was most respectful in terms of honouring the person that they were". And I really noticed at that moment, the way in which the system is designed around the needs and the ideas of almost one very specific sense of principles and values. And then you see this with hair in schools; there was the actress Tandy Newton spoke about her experience as a young person of always being told that her hair wasn't neat, because she has Afro textured hair, and how I think that's a perfect example of what I mean when the system is designed around the needs of white, middle class men, is that yes, to cut their nails and to brush their hair would absolutely be a way that honours their life. And yet, we can't assume that that always works for everybody

Gill Phillips  16:09

And might be completely wrong. 

Rosie Murphy  16:11

Absolutely, and be so devastating to the wider family, when they see that person with their nails and their hair in a way that's just not representative of the way that person chose to express themselves through their nails and their hair. And seeing how the system just doesn't really hold space for that was a real eye opener for me.

Gill Phillips  16:33

It's incredible, these defining moments, aren't they? We've all got them. Just things, you know, so personal, like that story that have got so many ramifications. I think that's a lemon light bulb moment, you know, it's a particular example. But it's so much wider than that, isn't it in terms of respect and understanding different cultures, and not imposing our own?

Rosie Murphy  16:56

Absolutely. Our own ideas of what's neat and right. And honouring that person in the way they chose to live their life.

Gill Phillips  17:05

And with the right intentions, isn't it? With the right intentions. But not thinking deeply enough? Or, you know, walking in the other person's shoes, isn't it in terms of what matters to them? I mean, I love the 'what matters to you?' movement, because it runs through all of this, doesn't it? And that clearly would matter to somebody, but isn't in the guidebook or the textbook as to how to go about things?

Rosie Murphy  17:30

Well, I'm delighted that I was able to point that out to this person. And therefore this wasn't a part of our guideline. But this was a person that I looked up to who was much more senior than me, much more experienced than me. And still in the NHS, it's such a hierarchical system that sometimes it felt a bit like, "Oh, can I say that? Should I say that?" And that I think speaks to other experiences I've had on my ongoing journey as a white ally. And it's very similar to a pledge I made at our workshop, Gill, which is about recognising that in order to effectively challenge situations where structural racism is playing out, as a white person, I have to be prepared to burn up a little bit of social capital.

Gill Phillips  18:25

So, what do you mean by social capital?

Rosie Murphy  18:28

And what I mean by that is, particularly as a woman, you're often encouraged to not rock the boat, don't say anything, don't create an awkward environment. And I think I've got better at this, as I've practised it more ...

Gill Phillips  18:43

You have. I've seen it! {laughter}

Rosie Murphy  18:49

But I am able to challenge things, I think, without triggering people's shame response or their guilt response.

Gill Phillips  19:00

it's a balance, isn't it? A line to tread.

Rosie Murphy  19:04

And I think being prepared to burn up my social capital a little bit anyway, is important. Although I also recognise that, as I said, white allyship is a lifelong journey. And you can't drag people up their journey. You can't drag them up their hill, you have to meet them where they're at. But I think that in this world of 'cancel culture', people are afraid of saying the wrong thing. And one of the important other things I learned about white allyship is I have to be prepared to take feedback on my racism.

Gill Phillips  19:46

Yep.

Rosie Murphy  19:47

Because I think that when we've grown and lived in a society that is systemically structurally racist, we haven't internalised some of this messaging. And I don't just mean we as white people. I think that this happens to people of all ethnic and racial backgrounds, is we internalise messages, in the same way that I've internalised messages that are probably anti-feminist about what my role is as a mother, in comparison to what my partner's role is as a father. And that we take in some of this messaging. And that's to be expected. But being prepared to take feedback on how my racism expresses itself is hard. But it's a really important part of white allyship. But I think and I hope, in that space, where I've learned how necessary it is, for me to be prepared to take that feedback. I can empathise that people, especially in this 'cancel and call out' culture, that it triggers a shame response to people and often makes them defensive. And I just have to credit a fantastic anti-racism campaigner called Nova Reid, who talks about calling people in instead of calling them out.

Gill Phillips  21:20

I love that Rosie ... "calling people in, not calling them out". How does that work 

Rosie Murphy  21:25

So what that looks like is ... somebody said something, and you feel that their thinking is underpinned by racism, that ... it's pausing and offering an opportunity for somebody to reflect on what's really upholding that sentiment that they've just expressed. And thinking about what assumptions perhaps they've made that had led to that statement. So it enables them to think, "Oh, gosh, did I just assume that women who live with high levels of deprivation, don't advocate for themselves? Because they don't have strong ideas about what they want their birth to look like? Or is it actually more because through their life circumstances, that they've never really been invited to advocate for themselves? 

Gill Phillips  22:33

But all based on massive assumptions, isn't it?

Rosie Murphy  22:36

Yeah, it is based on assumptions. And I think that with anti-racism, there's definitely a lot of it is going on at the unconscious level. But I think that there's an onus on us to stop and notice what those biases we hold are. And I think to give an example, of myself, because I think we have to be prepared to own our vulnerabilities about this in order to be able to move forwards. I have two children. And I sometimes feel that that's at least one and a half children too many. And I think therefore, as a consequence, I have in the past found it hard to identify and empathise with women I've taken care of who have large numbers of children, so 6, 7, 8 children. And I think that probably, that sort of alienation from these women, and not being able to really put my feet in their shoes and walk around in them, inevitably, has impacted the way in which I interact with them. And I think that some of this is just the way our brain works. It's the filing and the sorting and making sense of the world. But I think that we've always got to hold space to be open to 'well, what assumptions have I made about this person in front of me, and based on what?' And now I've realised that I hold or I held that biased assumption about what this woman who chooses to have a much larger family than I have chosen to have, it means that I'm cognitively aware that I might be making assumptions about how she might want to give birth or feed her baby that are just grounded in my assumptions and not in reality at all. But having that awareness that I need to remember to challenge my assumptions and just ask her "What would you like for this? What would you like for that? What do you plan to do for this?" is so helpful?, because if I hadn't realised that how intimidated I feel at the prospect of having eight children impacted, you know, that was my own feelings about that. And it's nothing to do with her. And yet, I was potentially allowing that to help me make false assumptions about what choices she might make during birth or after having the baby.

Gill Phillips  25:20

Yeah, thanks, Rosie. I think that's really honest. Because whatever it might be, I'm sure we've all got our own inevitable assumptions that we make, either consciously or unconsciously. And I think the key message that you're putting out there is that the more we do to become aware of that, then the more we can just treat each person as a person and not be making any kind of judgments about them, and treating people equitably.

Rosie Murphy  25:48

And I think that, for example, so much rhetoric at the moment about asylum seekers, but then when you think about 'What is an asylum seeker?' - it is somebody seeking asylum! You know, they've they've upped and they've left their desperate circumstances in hope of a better life. And yet, we've perhaps, taken on some of the negative stereotyping or headlines that we're fed, because that's inevitable, and forgotten, that these people are absolutely worthy of help.

Gill Phillips  26:24

I think you're going into some really interesting territory here, Rosie, which is much wider than this around stereotypes and stereotyping. So something, you know, the Family Integrated Care project that we're doing, at the moment, the digital Whose Shoes project with the Q community. Now, something that I'm very keen to include really is around health inequalities and assumptions that might be made on a neonatal ward. So just as you've been very honest, I think and it does take honesty, to tell us a little bit about your feelings when perhaps you see that mother of the huge family and that's not your experience, and so on. I'm fascinated, really, by within a neonatal ward, you will have a feeling that people are unlucky to have their baby having that particular experience, or the family having that particular experience.  But what have you a young mum living with high levels of social deprivation? Is your experience perhaps that people are more judgmental? I don't know. But I think in terms of Family Integrated Care, families come in all shapes and sizes. And you want every parent with a baby on the neonatal ward to feel that they're being included and encouraged and fully equipped to take their baby home. Not just everything geared perhaps to the the white middle class parents, to be honest.

Rosie Murphy  27:51

Yeah, absolutely. Gill, I think this is a theme that is sort of emerging. I think that, for example, not that long ago, for that young mum living with high levels of deprivation, in the maternity part, before she's had the baby, if, for example, she repeatedly 'didn't attend', there is always a sense of, "Oh, well, we can't just go around to her house and do this for her. She's got to take responsibility for herself". But that sentiment fundamentally overlooks the obstacles that she faces to get to the hospital in the first place. 

Gill Phillips  28:29

Exactly. 

Rosie Murphy  28:30

So for example, she probably doesn't have a car. If she has a driving licence, she has to get there on the bus. Does she have the financial means to afford the bus travel? If she's been diagnosed with gestational diabetes, she's highly likely to be needing to come to the hospital every week, perhaps for a scan or a diabetic appointment? Or perhaps there's growth scans, perhaps she's also a smoker as well, because we know that is strongly associated with deprivation. But does anybody stop and ask her? "This is your care plan? Is this going to be viable for you? Are you going to be able to get to the hospital this often?  How many buses you have to take to get to the hospital?" All those sorts of things. And then that poor lady, then she has her baby. Perhaps she has the baby early because she's a smoker or because she's got diabetes and has to be induced early and that's why the baby is in neonatal. The sort of blaming of her that potentially can go on. And not only is that distressing for her to be even subconsciously aware of, even if it's not overtly said that people are blaming her for the fact that her baby is in neonatal unit, but also the way in which that really fractures her trust in the service, in the institution, the relationship that she has with the healthcare staff, the relationship potentially she has if she does have social services involvement as a young mum, but she absolutely may not do as well. That's potentially a huge assumption being made ...

Gill Phillips  30:09

The relationship with other parents on the ward, possibly ...

Rosie Murphy  30:13

Yeah, absolutely the relationship with other parents on the ward and if she's a smoker, and having 10 cigarettes a day are the things that manage her anxiety and keep her going, and yet she feels scorn is poured on her in the neonatal unit, because she comes in and she smells of cigarettes and, and the kinship that she misses out on with other neonatal mums. Because that's a huge part of having a baby, certainly, once you get out of hospital, but probably for mums who are in, or their babies are in hospital for longer, as well as is the support from other parents on neonatal. And she's excluded from all of that. But just going back to the trust issue, because it leads me on to something that I saw came up at the Tackling Inequalities conference last week or the week before, at the Royal Society of Medicine, of trust as a social determinant of health. And it's so articulately and elegantly and concisely put, but that was a huge part of my Darzi work, the mistrust and the distrust of the NHS, and of maternity services in particular within that, was absolutely profound. And that was nothing new. Because I think that the COVID vaccine rollout programme had identified that the way in which the NHS can put a message out, and it doesn't land equally in all sectors of society. And going back to what I said near the beginning, the over-extending the reach of your service to bridge that gap, the vaccination buses, I'm sure there was a catchy term for them. But the whole taking vaccination right into the heart of communities where the uptake of the universal offering of the vaccine where you go online, and you book an appointment, and you come to this place at this time, where that wasn't cutting through. But I think that that opened the eyes of so many people in the NHS, of how we can't just have a universal offering and expect it to reach all sectors of society. Because there are parts of the nation that, as much as they might occasionally or perhaps less than occasionally at the moment, complain about the pitfalls of the NHS, are very confident in utilising it and navigating it. And then there are parts of society where it's an absolute minefield to navigate if they're willing to navigate it in the first place. And, again, going back to trust, that if people have experienced micro aggressions, for example, as part of their NHS Care, whether that's maternity care or whether that's other sectors of the NHS, the threshold of concern that they have to reach in order to be prepared to sign up for that again, and engage with the health service over whatever this particular concern is, is already higher. So that illustrates how this 'trust as a social determinant of health' plays out. And I hear this ... sadly heard it in Croydon, often, from women I spoke to that they almost had to brace themselves for engagement with maternity services; routine appointments less so. But for example, this wonderful woman who was so generous with her time talking to me about her experiences of having a baby that she was talking to me about having her second baby whilst being pregnant with her third baby, that she could remember having gone into triage, and wanting to get her maternity notes out of the basket underneath the buggy of the first child and have them in her hand lest she have to reach down to pull them out of the basket in front of the midwife because she knew all of the tutting that would have gone on that she didn't already have everything ready to go. The minute she walked through the door. And to be prepared to sign up for that. She had to be genuinely very concerned about ... I think it was abdominal pain she was experiencing and, if my memory serves me correctly, it was caused by a urinary tract infection. So she was absolutely right, 100 per cent right to be seeking care. But she really had to brace herself for it, because of her previous negative experiences. Now, if she's walked into triage, and she's already got her notes in her hand, nobody was tutting. So she'll never know whether that would have been her experience. But the very fact that that was her expectation is such a barrier to engaging in the first place. And I think it's things like that, that perhaps the NHS just doesn't really have a grip on; the way in which trust or mistrust of the system plays out differently in different socio-cultural groups within society. And what a profound impact that can have on care seeking behaviour. And ultimately, therefore, the clinical impact of that.

Gill Phillips  35:54

That's such a good example. And I think trust and being listened to, and being taken seriously ... they're, through our Whose Shoes work, they're the themes that come through all the time, regardless of the subject. And I think the examples you're giving of how deep it runs, really, and things that people would never see, you know, that anxiety to be fully prepared, so that you're not judged. I think we've all got that ... you know, that anxiety with healthcare appointments. But if you think that something about you ... the colour of your skin or some assumption, is going to make that worse for you, and possibly put you off attending the appointment at all, or reaching out. And then we wonder how these statistics that make outcomes worse for people from certain communities, why that might be ... that as well as the big things, there is going to be all these subtle, day-to-day situations feeding into that longer term outcome?

Rosie Murphy  36:56

Absolutely. And I'm glad you brought up the part about women feeling like their concerns aren't listened to and then not taken seriously. Because I noticed from listening to your big friend #FabObs Flo, her podcast about the CQC maternity survey, the most recent version, that that is deteriorating, that that's on a decline in comparison to five years ago, the proportion of women who  thought their concerns were listened to and taken seriously,

Gill Phillips  37:27

Which has got to be the number one question, hasn't it? I think Flo talks about all sorts of different indicators. I listened to that podcast, and thought it was fantastic. But if you pick through all of it, if you've got concerns, and they're not taken seriously, then that is likely to lead to bad outcomes, isn't it?

Rosie Murphy  37:45

Yeah. And I think it's baffling, isn't it, in some respects, because that's so obvious to sit here and think that. And yet, I think that what drives that, in the clinical setting is much harder to notice when it's happening. And it leads me on to this idea that I might have shared with you before. And when I first started saying this, she was the Duchess of Cambridge, but she's now the Princess of Wales, and that if you look and sound and speak, like the Princess of Wales, when you walk into maternity triage, the extent to which people are going to take your concerns seriously, is absolutely maximum. But I think, change her educational status, her socio-economic status, her ethnicity, her body size, all of those sorts of things. And suddenly, the extent to which what she says is seen as important, just goes down and down and down with changing each of those, some of which are protected characteristics. And I think we have to be realistic about that in maternity. And I think that that was a big lightbulb moment for me. But going back to what I was saying about women who have large families is that was probably feeding in to my ... the extent to which I took their concerns seriously, because we all operate in this system of medical paternalism, where on some level, we the clinicians know best. We've gone and we've studied and we've got experience, and we know best But actually, as a midwife, and I hope, as as a strong advocate of women, we have to hold space for women, knowing themselves, knowing their bodies, listening to them when they're concerned and taking those concerns seriously. And that's not to say that there's no space for professionals. It's not that at all. It's about using both. It's use the wisdom and the experience of the clinician, but also use the wisdom of the mum as well, or the birthing person. Because both of them are equally important. I'd delivered countless babies before I'd ever had a baby of my own. I knew what I knew from that perspective. But I'd never been there, myself. And even now that I have been there twice, I couldn't even begin to suggest that just because I've had two children, that I understand everything that everybody's going through, because no two births are the same. But I think that, certainly, with how much pressure maternity services are under, and the lack of opportunity that we have often to build relationships with women, that we don't do that well. We don't take women's concerns seriously. And the impact that has plays out differently for different groups of women.

Gill Phillips  40:59

 Yeah 

Rosie Murphy  40:59

Because there are some women who are very confident to say, "You're not listening to me, you're not taking my concerns seriously 

Gill Phillips  41:06

And it's interesting, when you were talking then about that list of different things that would chip away at that presentation, you know, the education, the perhaps body size, the colour of the skin, or whatever, I was thinking ... and confidence! Because it could be that someone's ... it's been so difficult for them to either come along, or to get round to, to raising that concern. I know, we've explored this a lot with our perinatal mental health work and the #MindNBody project. So that if somebody doesn't build on that, and sort of either slaps you down, or minimalises it as you're speaking, and as you've raised your concern, you're not going to be doing it again. So all these different themes, isn't it? Speaking out ... trust ... I know earlier, when you were talking about speaking out in a hierarchical system, such as the NHS, the confidence again to do that, and depending on how that person reacts to you, that's going to feed your next experience, and perhaps you won't go there again. And I know we were talking before we started about #NoHierarchyJustPeople, and how that's kind of central to Whose Shoes, so to get these women able to come along to perhaps a workshop, as we did in Croydon, and speak together as equals and know that they are being listened to. And I thought the HEARD campaign in Croydon, which obviously pre-dated our workshop, and the whole concept of that, was really, really powerful. And I don't like acronyms, but I like that one a lot. So tell us a bit about the HEARD campaign.

Rosie Murphy  42:45

Yeah, thank you so much for bringing that up, too. Because I'd have been absolutely mortified if we got to the end of this and I hadn't even given the huge amount of praise, where it's due to my colleagues Olamide, Gina, Helen, and Ranee, for setting up the HEARD  campaign. So HEARD stands for Health, Equity and Racial Disparity. But the reason why you like that acronym is because it's obviously about women being able to get their voices heard, and how important that is, and how often difficult that is, particularly for women with lived experience of racism, or experiencing high levels of social exclusion or disadvantage, not having English as a first language. So the idea behind HEARD was to really create a service that better met the needs of these women, and recognise the way in which the universal offering wasn't sufficient. So it did introduce things like additional antenatal appointments, and longer antenatal appointments. But what it also did, and it wasn't even a big deal, but the impact it could have ... it wasn't even a big idea. But the impact that it had was massive, which was to just set up an anonymous email account that women could contact if they didn't think their concerns were being taken seriously. Now, obviously, in labour, that wasn't really going to be viable, because you needed a time-critical response. But certainly for women in the antenatal period, if they felt that their concerns weren't being taken seriously, they were able to email this email address and have somebody just sort of listen to them, coordinate their care a bit, and if necessary, sometimes just suggest seeing a different care provider, you know, different midwife in a different clinic and to let that midwife know well, actually, this lady is coming to you because she very much felt that when she was under the care of this person, that her concerns weren't taken seriously. And it's little things like that, that just make such a difference. And then they put loads of posters around the hospitals so that women would actually see it was there and know it was there. And the other thing they did, which I'll be forever grateful that they did, is they set up a survey. So they did staff and service user surveys about their experiences of maternity care. And it asked a number of things that were fairly similar to the CQC maternity survey, but a different time interval, and purposefully asked women from minoritized ethnic backgrounds to complete it. If you've started filling it in and you said your ethnicity was White British, the survey would just end. So it was a survey specifically to ask women from minoritized ethnic backgrounds, what their experience was like, of their maternity care at Croydon, and it was because of the findings of that, that they ever decided to get a Darzi Fellow in the first place.

Gill Phillips  45:56

Wow. That's just so simple, isn't it? If there isn't a national survey, and the CQC seem to be catching up a little bit in that the question is now asked about ethnicity, and the analysis is starting. But I mean, I know when I listened to Flo's podcast, and she was talking about, I think it was a 46.5% response rate, which is pretty good. But, you know, the kind of questions going through my mind is, I wonder who it was that didn't reply, and almost that you could have an amazing research project around that, because that would unearth so much. And I bet there would be people disproportionately affected who, for whatever reason, whether it's trust, whether it's technology, whether it's the time and the capacity, whether it's, you know, whatever it might be, but I'm always interested in who didn't reply. And whether the people who did reply are the people who would always reply, and that's already quite a split, isn't it? There's so many layers to this stuff isn't there, it is just fascinating and important.

Rosie Murphy  47:05

Yes, absolutely. Just so important, that 'who didn't reply, and why didn't they reply?' Because I certainly remember, when the 'Invisible' report was published in the summer, that alarming numbers of women reporting very high levels of dissatisfaction with their care but tiny portions of women had complained, either formally or informally. And, well, there's a number of different things there. Number one, I'm always talking to my colleagues now about our ... I call them blind spots. What don't we know, that we don't know. So whose voices aren't we hearing? And we don't even know we're not hearing it. 

Gill Phillips  47:50

Brilliant. Yeah. 

Rosie Murphy  47:51

Because I think there's a huge health inequalities domain to that.

Gill Phillips  47:56

A bit like the Johari Window, isn't it? 

Rosie Murphy  47:59

Yeah, or the other one is the Donald Rumsfeld speech. 

Gill Phillips  48:02

Okay. 

Rosie Murphy  48:03

The known knowns and the unknown knowns and the ...

Gill Phillips  48:06

Yeah, all of that. Yeah. But it's fascinating.

Rosie Murphy  48:09

But recognising that, in such a data led world, we've got so much data now and the NHS has come on in leaps and bounds in terms of its data collection. But still, we don't hear from everyone. And we don't always know who we don't hear from. And what we especially don't know is why we don't hear from those people. So, for example, I spoke to lots of women in my year in Croydon, and lots of them told me things that I'll never forget. I bet because it was so distressing to hear about what their experiences were, but not a single one of them had complained. But not only that, but in this system in the NHS, where we have friends and family feedback, we have the maternity survey. And we have the Maternity Voices Partnership. And when I think in comparison to ...  you know, I can't renew my car insurance without filling in a feedback form of what was it like today, or buy anything online.

Gill Phillips  49:15

A single purchase on Amazon, you know, for £2.50. What was your experience like? Crazy!

Rosie Murphy  49:22

Absolutely. That why haven't we created more channels, for women and families, to feed back what their experiences of their maternity care were? Because that's the only way that we can make improvements, is if we know. But I also appreciate that, for example, the women I spoke to in Croydon, where I was distressed just hearing about what they'd experienced. Of course they weren't going to feed that back. Because their expectation that something would be done about it was absolutely rock bottom.

Gill Phillips  49:59

And fear of speaking out as well in terms of any repercussions, perhaps they're pregnant again or might be in the future or their friend is or a family member ... Picking up there, on a more positive note. So we're talking about communication channels and the kind of thing that I absolutely love - and one of them jumped out, a tiny thing from one of your reports for the Health Innovation Network, was hairdressers. So, in terms of communication, these are the kinds of examples that I love with Whose Shoes - you know, what can we do about it? What little thing? Well, people go to their hairdresser, they chat to them, they trust them, they've probably got a relationship. And then the hairdresser says to them about the importance of early referral to maternity services. Now, I understand there was some training there for hairdressers. And similarly, the kind of examples going through my head in terms of innovation and building perhaps more positively on the kinds of things that came from the pandemic. So my very first podcast guest was Dr. Farzana Hussain. And I love Farzana because she was doing things like a walk-through immunization service for children during the pandemic, so that they didn't miss out on their jobs. And we were talking earlier about trust. And we were talking about COVID, vaccinations and so on ... I remember hearing about a GP, who basically had some brazilian cleaners, and they were aware of the brazilian population, which was apparently quite a large local population, typically not taking up COVID jobs, for various reasons that obviously were really important to them. So to get the cleaners to be saying to their friends in the community, "Come along for your jab, there won't be nosy questions asked that you're worried about, the GPs just want you to have your jabs". So to find ... unusual routes I think, to work with where the trust is, and build relationships. And I think, the thing I really wanted to mention was in Noreen's podcast, I just saw it as a bit of a gold standard in terms of, you can't do this stuff as a quick fix. You know, if there's deep rooted mistrust, then you can't just come along with an initiative or a short term project and hope to solve it. And Noreen was talking about the way that services and trust had been built over I think it's about 30 years, and how the different community services fitted together. And if you took one of them away, no longer funding that short term project, then you're not just randomly removing something, you're like taking out a piece of the jigsaw that really matters in terms of how the whole offer fits together. Now that's what I saw the similarity with Croydon.

Rosie Murphy  52:57

Yes. And I've listened to that episode with Noreen Bukhari and listened to it and just said, "Yes, Noreen!" repeatedly throughout it, because so much of it spoke to exactly what I'd identified in my Darzi fellowship, and to know that she's been there with with that organisation doing this work for such a long time. I thought I could have just gone and done a case study of that.

Gill Phillips  53:22

Well, perhaps you will, yet. That's what I mean about the connections; you two need to connect things.

Rosie Murphy  53:27

Definitely. And, and there's always the argument of local solutions for local problems. But so much of what I learned, I could have learned from listening to Noreen as well, that, that, especially tackling health inequalities, we really need to take a community first approach that ... and I had to push back quite hard on this, in my Darzi fellowship, this expectation that because these inequalities were playing out within the four walls of the hospital, so i.e they're playing out when women are coming in, in labour, that the solution must be within the four walls of the hospital. And I had to push back and say no, these inequalities may be playing out there. But they are so deeply embedded. They're in place, usually before this woman's even pregnant, but certainly before she stepped foot inside the hospital, and that really to be able to move the needle on this issue, we need to be collaborating with our communities so much better. And what I learned and again, Noreen said as well, is that the voluntary sector and the community have the capacity to reach into spaces that the NHS just can't penetrate. And that is what we really need. It's like you say it's the Brazilian cleaners using them as a segue into that sector of the community. Because we, for reasons we don't understand as the NHS, because you can't see yourself from the outside, like a fish can't see it's in water. That we need to get much better at collaborating with our voluntary sector partners. And that came across so strongly to me in Croydon, because I collaborated with some absolutely fantastic organisations that I know had a reach into communities that I would never have been able to access.

Gill Phillips  55:24

And some of it just so simple, isn't it? The cleaners who've worked there for a long time, trust the GPs; the cleaners' friends trust them. That was a very short route, and would have taken forever to do it formally through the NHS; it's as simple as that sometimes. 

Rosie Murphy  55:40

Absolutely. 

Gill Phillips  55:42

And the hairdressers, the same.

Rosie Murphy  55:44

I didn't ever get as far as I wanted to. And I also have to point out that the hairdressers wasn't my idea. That is an idea that somebody shared with me, that has been used both in a men's mental health capacity, and also nutrition and dietetics for diabetes and heart disease in South East London.

Gill Phillips  56:03

Brilliant. And it doesn't have to be one person's idea. It's everybody's idea, isn't it? It's just ... and that's where we need to share?

Rosie Murphy  56:09

Absolutely. Just having people being able to just casually say, "Oh well, actually attending all of your antenatal appointments is really important. So if you can't go, tell the hospital that you can't go to this one, and they will rearrange it". Because, for example, to people who are new migrants to this country, or perhaps whose parents were migrants to this country, the way in which you understand how to navigate the health services is something that you acquire through your childhood of utilising the NHS. And one of the things that I also became aware of during the Darzi fellowship, where I began collaborating with other sectors of the health service in the community, was ... Oh, my goodness, maternity services are difficult to navigate! When I sat and thought about, well, if I have this problem at this point in the pregnancy, so for example, let's take pregnancy sickness: pregnancy sickness, in a mum presenting around seven weeks. She hasn't yet had her booking-in appointment at the hospital. She's been referred to the hospital. And so she might have the date of it. But she hasn't been seen by anybody yet. But she goes to the GP. And the GP says, "Oh no, pregnancy, you have to go to the hospital. But she doesn't know where in the hospital. So she ended up going to A&E. Now, I'll never fully understand this. But in my clinical experience, people who don't do maternity are terrified of pregnant women 

Gill Phillips  57:36

Yes. And that links in with the work that we've done with London Ambulance Service. And particularly recently, I did a big virtual workshop around triage in maternity services. And it's the most complex thing I've ever done. I think in terms of the number of different possibilities, depending on who you are, where you live, what's available locally. What you might know, what leaflet you might be given, whether the phone numbers are out of date. And then you get to ... well ultimately, if you phone A&E, you get an answer. And you get a translator. And then they wonder why so many people go straight to A&E. And it's like ... when you dig and find the connections, some of it becomes a bit more obvious.

Rosie Murphy  58:25

Absolutely. And what it was that prompted this conversation was I was having a conversation with a GP who I collaborated with in Croydon, so she's a GP and this was her talking about her sister and her sister's experience of ... not at Croydon, but at a different hospital ... of trying to get somebody to check her over, help her with her pregnancy sickness. She was obviously concerned she was dehydrated, but also she was feeling absolutely dreadful. So without her sister being a GP, this woman would have had a really difficult time trying to get the care that she needed. But then, in most cases in early pregnancy, before they've even booked in, that's not the kind of care episodes that have a significant impact on later on in the pregnancy. That's where things like having booked in for that risk assessment later play a greater role, and also not attending all of your antenatal appointments. Those are the factors that play a much more predictive role in a adverse outcome in maternity. But it just really hammered home to me that maternity services, and like you said with the triage event, are so difficult to navigate because it depends what gestation you are and what the problem is, as to when you go where. And in maternity services, when you know the system, it is so easy to lose sight of that. But then when you add in a language barrier, mistrust of the health service, or other factors like that, and all of these factors conspire together to completely change the opportunity to engage with the health service. And that plays out differently for different sectors of society. But bringing it back to community, one of the fantastic organisations, I'm going to name them both because they're brilliant: Croydon BME Forum  

Gill Phillips  1:00:21

Yes!

Rosie Murphy  1:00:22

And the Asian Resource Centre, Croydon ...

Gill Phillips  1:00:24

They were fantastic!

Rosie Murphy  1:00:25

Absolutely fantastic. And really instrumental in making the workshop the success that it was, but really instrumental in helping me to understand what's really going on here; what's upholding this perinatal inequality. But I know that for example, Asian Resource Centre, just this wasn't a maternity specific thing. This was just like a healthcare drop in for people who trusted the Asian Resource Centre, but perhaps wouldn't have necessarily sought out their GP. And on this one day, they identified one gentleman who was so hypertensive, he had to be blue lighted to A&E, a number of others who had undiagnosed hypertension who were referred on to their GP. And I think they had about 25 people come. So that's three significant health care needs met, but also somebody else who had very high blood sugar reading, so quite possibly had undiagnosed diabetes. And that's just as a cohort of about 25 people. And that reach, like we're saying, that that community organisation has into that population, that the NHS just doesn't have. And I think that the NHS was so oblivious of the fact that it didn't have that kind of reach. And now, probably, since the pandemic a lot more recognise that and recognise the need to work collaboratively with these community organisations. And I really hope that with the creation of the new ICSs, the Integrated Care Systems, where they are designed to join up to collaborate with community organisations, that that's the way that we're going to see change, and more effective tackling of health inequalities, because there is now that widespread recognition of the NHS is great at some things, but sort of tapping equitably into all sectors of society it is not great at. And we need to maximise the fantastic voluntary sector organisations that we have to be able to bridge that gap to over extend the reach on our behalf.

Gill Phillips  1:02:41

So that's a strong message, isn't it? So a lemon light bulb, I think to end our, our podcast. And I love the idea, Rosie ... we were talking about dissemination. So hopefully, the podcast and hopefully, I'm sure, Florence, Wilcock will give you a slot on the ObsPod. Because she has helped so much with all this work that we've been doing and helping with the work with your Darzi fellowship and preparing for the Croydon workshop, although, sadly, she couldn't be there on the day. So I think dissemination ... and I absolutely love the fact that you've chosen to write up your three blogs for the Health Innovation Network and understand that they've been very successful in terms of people actually reading them. So social media, obviously is a big part in that I think compared with having ... your work would deserve a really polished paper. And I'm sure that if you get round to doing that, then you could be presenting at World conferences, and that paper probably needs to be written. But in the meantime, that might take a long time, but to JFDI and have some quick blogs and a podcast. And we can share the links to those obviously, as you've said, in the podcast notes. And I'll be very proud to share the little video that we made of the Croydon workshop. And the ripples from that are strong, and they're continuing. And hopefully in terms of more Whose Shoes work that we're working on. These things are very difficult to measure. And at some point, I think a big part of my work is: don't spend too long measuring it, spend your time trying to actually do it and you know, the action focus and working with people building networks and taking it all forward. So thank you, Rosie, for talking to me today. It's been absolutely amazing.

Rosie Murphy  1:04:26

Oh, thank you so much for having me. It's been wonderful. And like you say just touching very quickly on that idea of dissemination that yes, I'm sure there is an academic article in me somehow and at some point, but I was just so keen to get the message out as quickly and as accessibly as I could because I understand the strain that people in maternity services are working under at the moment and those three very quick reads, I felt was the best balance between getting the key points out there without making it 10,000 words ... and nobody having time to read it. So thank you so much for the opportunity to talk about it on here as well, because that will definitely help disseminating the ... not even the ideas, I think just the learning: the learning, because I've been given this golden opportunity.

Gill Phillips  1:05:15

Well, I know that when Florence and I did the 'Nobody's Patient' project, we had to do a monthly report for NHS England. And we did it as Steller Stories. And nobody told us we couldn't, and people actually looked forward to them and read them. And now with the Family Integrated Care report, I'm just at the moment preparing a report using SWAY, which is another kind of storytelling tool that I've learned from Lyse Edwards from the Midlands Partnership Foundation project that we're doing. So I think exchanging these more kind of creative ways of actually sharing the key learning. And the blog I wrote this month for patient experience library with Miles Sibley, just capturing some of the key learning and lemon lightbulbs. And I think the way that Flo builds a zesty bit in at the end of each, the ObsPod podcast, with practical learning that people can take away immediately from each episode. I think this is the way to go when people are busy and also human in terms of being a little bit more engaging.

Rosie Murphy  1:06:22

Absolutely. I couldn't agree more Gill. So thank you ever so much for having me on.

Gill Phillips  1:06:28

I hope you have enjoyed this episode. If so, please subscribe now to hear more of these fascinating conversations on your favourite podcast platform. And please leave a review. I tweet as @WhoseShoes. Thank you for being on this journey with me. And let's hope that together we can make a difference.