Every child who is still born is a personal tragedy for the family. Sharon Hodgson’s moving personal story in the House of Commons this week is testimony to the tragedy. For a health service it is part of the measure of the standard it is achieving in maternity care. The current changes in our NHS maternity provision are not based on solid evidence. This raises the question that they may not be safe, effective or likely to lead to their stated objectives including a reduction in still births.
Maternity services in England have undergone an almost silent revolution, while the focus has been on hospital downgrades and closures and the loss of GP services. The National Maternity Review, Better Births – A Five Year Forward View for Maternity Care, is one of the Five Year Forward View’s New Models of Care. As with all new care models, it emphasises community care delivered through local hubs with a theoretical reduced demand on hospital services. It recommends an increase in independent sector providers and introduces Personal Care Maternity Budgets (PCMBs).
44 Local Maternity Systems have been established that are, for the most part, co-terminous with the Sustainability and Transformation Plans (STPS). The changes have been implemented without consultation, peer review, pilot studies or effective oversight from public health or parliamentary scrutiny. They are small-scale Integrated/Accountable Care Systems. Unlike the Integrated/Accountable Care Organisations which are now on hold, they have been put into place with very little fanfare or institutional opposition.
As with all the changes to the NHS currently taking place, there is a real problem that rhetoric about better care closer to home is not matched by real resources or access to physical structures like hospitals. NHS England-produced documents consistently refer to services being more important than organisations but fail to fill in the blanks about how this works. They also insist that travelling in order to receive excellent care is not a concern to patients. There is no acknowledgment that time, expense and severity of health condition all very much effect the distance people are able to travel regardless of the excellence of the service at the end of the journey.
In the case of maternity, these questions of distance and the emphasis on community care run two different risks. The first being the potential for increase of emergencies outside hospital setting. The second is that mothers might be taken in to hospital for assisted birth or caesarean in order to pre-empt risk arising.
Why is Maternity so important?
Most people use health services most at the beginning and end of their lives. Pregnant women are the exception to this. During pregnancy women come into more contact with the NHS than they probably have ever done in their lives. This is particularly the case if they have a complicated pregnancy or birth. Healthy women can become profoundly unwell during pregnancy and they can be vulnerable to life-threatening complications during birth. That’s why it is so important that women have all levels of care within easy access.
Until now maternity services have been provided in the most part by the NHS. Women have always been free to employ a private midwife or doula to support them during labour if they choose to do so. But the NHS has a duty to provide a midwife at every birth even if a private midwife is also in attendance.
Since the Health and Social Care Act 2012, despite the commissioning of services being further outsourced via Clinical Commissioning Groups (CCGs), provision has largely remained within the NHS.
Maternity services are woven through the traditional structure of the NHS. Women see their midwife at home or at their local GP (this option may diminish as GP practices close, in contrast to the ‘closer to home’ mantra). They receive a minimum of two scans to check the baby’s progress and health at the local hospital. If they have a pre-existing condition or they develop a pregnancy-related illness then their specialist will work alongside the maternity team to ensure that the woman and baby are safe and as healthy as possible throughout the pregnancy.
Currently women can give birth at home, in a ‘stand-alone’ facility run by midwives, ‘co-located midwifery unit’ (a midwife-run facility on hospital grounds), or in an obstetric unit which includes doctors and surgical theatre. Obstetric units can only be sited in hospitals with A&E because they require acute services (blood, air and surgeons). A woman can become dangerously ill very quickly during birth so timely access to acute care is essential.
Maternity should be the one of the jewels in the crown but it’s fast becoming one of the Cinderella services of the NHS.
Since 2010 maternity services have been starved of funds and there has been a staff recruitment and retention crisis. One third of midwives leave the profession within 10 years of qualifying. The Royal College of Midwives estimate that there is a national shortfall of at least 3,500 midwives.
Many maternity units have already been downgraded or closed, hundreds of GP practices have also closed so women already travel further to receive care. This means it costs more and takes more time to see a midwife, GP or hospital doctor. It also means longer emergency transfer times. The risk is this will only get worse once the STPs restructuring of the NHS is complete.
In November 2016, Professor Chris Ham, Chief Executive of The King’s Fund, said:
“STP driven downgrades of certain services were in effect painful medicine that the NHS had to take to ensure it survives. The public may be understandably concerned about travelling further to access A&E care but in many cases that will be a price worth paying for a higher standard of care, and the same would apply to maternity services. Overall this is a painful process that the NHS has to go through.”
Who is driving the changes to maternity?
Better Births – a Five Year Forward View for Maternity Care sets the agenda for change but the Review’s panel includes private health providers. The Chair, Baroness Julia Cumberledge, owns a company that provides services to the NHS. A private midwife company, Neighbourhood Midwives, also contributed. Private health providers are working with government to shape policy.
The emphasis on the Better Births review is on the following areas:
- An increase in deliveries at home or in midwife-led facilities
- A network of Local Maternity Systems (LMSs) which bring together commissioners and providers
- Women can choose their provider who can be outside the NHS
- Introduction of the Personal Care Maternity Budget
- Centralisation of specialist obstetric services in fewer hospitals
44 Local Maternity Systems = 44 Integrated/Accountable Care Systems
LMSs bring together commissioners and providers of care. They share the same geographical footprints and structural opacity as the STPs. They also share their lack of accountability.
LMSs are Integrated/Accountable Care Systems (also called place-based, accountable-care or horizontal and vertical integration – they’re all the same thing). Although most current providers are NHS hospitals, private providers are strongly encouraged. LMSs set their own payment systems. This means that they can choose whether they pay via their geographical population (the STP footprint) or they can pay per activity or service. However, they do not follow established budget areas; they do not share boundaries with CCGs or Local Authorities even though they rely on budgets from both. Across the country there is now a mish-mash of payment systems. The risk is that women will fall through the gaps.
NHS Trusts have been ‘incentivised’ to adopt Better Births by offering a chance to win ‘pioneer funding’ to speed up the transition to the New Models of Care. In November 2016, Seven ‘early adopter’ sites started to implement the recommendations. They were told to be bold and radical. Another is ‘the maternity challenge fund’ which instructs successful trusts ‘to explore innovative ways to use women’s and their partners’ feedback to improve maternity services’. A pioneer site is not the same as a pilot test site. The choice agenda is one that will win favour with parents and patients alike but choice should not be confused with evidence-based evaluations.
Call the Midwife – if you can afford one. The role of private midwife practices.
LMSs are encouraged to work alongside private providers in order to offer women a wider choice of provider. As most women have previously been cared for by the NHS this means opening the door to the private sector. In a climate of serious staff shortages, it is possible that some midwives may see the benefit of setting up an independent midwifery practice rather than staying in the NHS. Despite protestations to the contrary, this reduces the ‘NHS offer’ and opens an income stream for public money to be handed over to the private sector.
Better Births is working on a new accreditation scheme for maternity providers. In a publicly provided NHS service, this is unnecessary because the NHS trains staff to a professional standard. It is unclear whether unqualified birth partners such as doulas, hypno-birthing practitioners, homeopaths, herbalists, mindfulness leaders or a yoga teacher can be included in the scheme.
The advice makes it clear that new providers (this means private) will be involved at every level:
‘The accreditation and contractual process to be able to provide maternity care under this scheme means that a new provider would be locked into the local maternity system, standards, quality measures and data collection that hallmark coordination. The ability to share facilities will enhance cooperation. All these alternative providers are currently outside the NHS with few cooperative mechanisms, this proposal changes that. Becoming part of the NHS family has obligations as well as opportunities.’
The NHS Guidance for Maternity Services says:
‘plans will need to consider the financial case for change, including overall affordability, transition and recurrent costs, assumptions about savings and how the transformation will contribute to the STP’s financial balance’.
One essential element for the case for change is that more women will be able to give birth in ‘midwifery settings’ (at home and in midwife-led facilities). In financial terms, births in hospitals are very expensive. How unqualified birth partners contribute to the financial case is not justified in the guidance. Nor is a potential increase elective or emergency caesarean as a consequence of the restructuring of services.
Studies and research into the potential effect of the changes currently being implemented cannot be undertaken without including social determinants of health. There is a rise in maternal obesity, we have a rise in the number of women putting childbirth until later in life and more women with complex needs in pregnancy increases doctors’ fears that they will be subject to a law suit if something goes wrong in labour. All of these issues contributed to a rise in caesareans.
Dr David Richmond, president of the Royal College of Obstetricians and Gynaecologists, said he was, ‘worried that an unnecessary high number of women whose first pregnancy progressed without any problem still ended up giving birth by caesarean’. Thirty years only about 10% of births were by caesarean whereas today it is about 25%.
Personal Care Maternity Budgets.
PCMBs are a radical move away from the way the NHS has always been funded. The ambition is that all pregnant women will be entitled to a PCMB of £3000. NHS England announced that 400 PCMBs were in place by June 2017 with the expectation for 10,000 by the end of the year. PCMBs commoditise and monetise the system. They add layers of unnecessary complication, increase the expense, fragment accountability and lead to an accounting nightmare.
Private providers are required to have a contract with the NHS in order to receive payment via a PCMB. It is claimed that the budgets (which are described as ‘notional’) will demonstrate to CCGs the kinds of choices women make during pregnancy, birth and postnatally. This will encourage CCGs to respond to women by increasing their offer. The claim is that this will also empower women. It is decidedly unclear about how this can be realistically achieved. The guidance talks about using PCMBs for birth pools, place of birth settings or breastfeeding support but all of this should be available to every woman regardless of a personal care budget. In fact, all of these used to be available to women as part of the normal care given by the NHS.
Moreover, it precludes the notion that women become ill in pregnancy. No one chooses to get gestational diabetes, pre-eclampsia, HELLP or any other life-threatening condition. What happens when your health needs change but you’ve used up your £3000 on hypno-birthing? There should be real concern about the potential lack of access to obstetric care when women have serious complications of pregnancy. Or to return to the issue of financial balance, if £3000 is a notional budget for a normal birth which can be used up in a number of ways then the acute hospital will potentially have to pick up the cost of the emergency care without a matching budget.
What does this all mean?
Scale and pace has taken precedence over caution and evidence. Academic research will take years to catch up to establish the public health consequences of the new policy.
This is a top-down reorganisation of a national service with a lack of consultation, pilot schemes, peer review, oversight or risk assessment. A Health Select Committee inquiry into the maternity transformation plan was not completed because of the 2017 election. It has not been re-opened.
The Vice-Chair of the maternity transformation programme finishes his report with the following advice to LMSs: Be Bold! Don’t wait for instruction! Long gone are the years of epidemiological study, of public health planning, of consultation with experts.
Better Births is based on consumer choice issues around personalised maternity care that claims to empower women. There is a serious lack of evidence that this restructuring will give women the vital services they need. Fewer services, obstetric departments being stretched even further and technology replacing face-to-face clinical care seems unlikely in reality to be able to match the Better Births’ claims. On the other hand, it embeds private care and fee-for-service in a which changes the face of the delivery of maternity care. This is not how a national public service works.