I have read about and listened to as many of the responses to the review as I could over the past week. On balance, I think they are largely very positive, I am heartened by the enthusiasm from midwives and other health professionals, while recognising, as we did during the review process itself, that many will be anxious about what it means for them personally.
What has been fascinating though is how many statements of fact have been made about how it will work, especially the NHS personal maternity care budget, which are based on nothing contained within the review itself because we deliberately didn’t set up rigid structures to impose on everyone – the point of pioneer sites and pilots is that they have the freedom to explore how these new ideas might evolve, based on some principles and guidance and an outcome or destination you want to arrive at but with the expectation that there will be lots of adaptation and change along the way.
For example, I’m not sure where the idea of paying for hypnobirthing came from as the amount (£3k) is based on the current tariff for a/n, intrapartum and p/n care – and that is what women will receive in exchange for their voucher. The real question is who will they be able to get it from and for many the answer will be the same hospital trust as now – but the difference is that, if the hospital says they can’t provide a homebirth for example – or that the birth centre may not be open, women should be able to challenge that response much more effectively than now because they will have become the ‘purchaser’ who the provider will be accountable to.
So, I have written down a few of the actual facts as we know them and a few of my thoughts about how and why we arrived at this idea and what some of the parameters are for those CCGs which express and interest:
- The National Maternity Review – ‘Better Births’ Improving outcomes of maternity services in England – A Five Year Forward View for maternity care was launched on Tuesday 23rd February 2016 and runs to 125 pages.
- Over many months during 2015, there were lots of meetings, discussions, evidence gathering, listening events and numerous iterations to get it to where it is now.
- The overwhelming message to the review team from women all around the country is for more continuity of carer.
- Evidence suggests that improved safety in childbirth is linked to continuity based models of care.
- Recommendations are just that – with a clear message that individual areas should take general principles and adapt to local need (see appendices of report for details and timing).
We have known for a very long time now that continuity of carer models have better outcomes, save money (for a whole range of reasons), reduce unnecessary interventions and are what women prefer – so the burning question is why haven’t we been able to provide it other than in small corners of the NHS in teams which can either burn out (overload) or be closed down with little warning and questionable reasons?
The range of key priorities and recommendations which the review has come up with are, in part to try and answer that question differently.
They are the result of a great deal of debate and discussion, based on available evidence, numbers/time frame etc and are ideas – some more radical than others – to try and inject some leverage and incentives to introduce change into a ‘stuck’ system which, although it does a great job much of the time, no –one thinks it is perfect and most agree it needs some sort of shift to enable all those women – who do not want to be, or need to be, on an obstetric unit but currently are – to be able to access more out of hospital births, either in FMU’s, AMU’s or homebirth.
THIS IS IN LINE WITH CURRENT NICE GUIDANCE (based on evidence)
No-one is suggesting that these changes happen overnight, nor is the review trying to say that it has all the answers, this is about trying to think differently about some of the challenges which have not been solved to date by the current system, despite having the evidence, policy and guidance in place.
NHS Personal maternity care budget:
- Personal health budgets are already available throughout the NHS and social care – it is not a wildly extreme idea to think about whether or not it could be extended to a particular group of users who for the most part, are not ‘ill’ but have some important social and emotional needs which are not always being met and who have a time limited condition – ie there are very clear parameters already in place.
- Women expecting a baby already have, in theory, the right to choose where to have their baby but often don’t feel that they can exercise this right within the current system.
- Putting ‘money’ into the hands of those consumers gives them power they don’t currently have – it sends a very strong message to the providers of that care that women do have rights.
(for the detail on this read ANNEXE C page 118 of the report)
- It is intended that there would be an initial phase with a small number of pioneer sites to test the assumptions and processes. ie it will not be available tomorrow morning to all women up and down the land.
- All providers within the scheme will need to be accredited. The process will be as non-bureaucratic as possible but is necessary to reassure everyone that public money is being spent appropriately (due diligence) and that the care is safe and meets national standards
- Scheme eligibility needs to be clear – the proposal is for standard tariff in the first instance (Approx £3k) but this is to test the system not to cherry pick… ideally all women, whatever their risk factors should be able to access this sort of care but it is important to learn lessons and widen access in a step by step process, if that is appropriate.
- Crucial to this is for ALL accredited providers to be integrated into local maternity system (community hubs) through clear pathways shared networks and good communication.
- It will be based on tariff so no more expensive than current system once up and running (small amount of money to enable trialling – £0.6million over next 2/3 years…pg 94)
- All accredited providers will have standard contract with NHS. They will not be the first in the history of the NHS to do so. ALL GPs are ‘private businesses’ who work through the Standard General Medical Services Contract, always have done – and no-one would suggest that they are not an integral part of the NHS… so why would it be any different for midwifery practices?
- It is voluntary for women to choose – IF THEY WANT TO
There are different ideas about how ‘top ups’ could be enabled for those women who develop or have additional risk factors (just as now) to still be supported by their midwife who could access the care they need through collaborative and partnership working, facilitated by networks and seamless care pathways.
If everyone committed to improving relationships, trying out new ways of working and giving different ideas a go – not as a whole system replacement but in small bite sized trial areas and done slowly and with thought and care …. Isn’t that a sensible approach – why wouldn’t we at least give it a try? When I hear people say ‘it won’t work’ or ‘its utopia ‘or a ‘fantasy’, my question to them is – do you have an alternative?