So just who does decide how maternity services are organised in this country? And whose interests do they serve?
In 2012/13 maternity care cost the country £2.6 billion. The Department of Health is nominally responsible for securing value for money yet since April 2013 actual local maternity services have been commissioned by Clinical Commissioning Groups (CCGs) who are in turn overseen by NHS England. Maternity care itself is currently provided by NHS Trusts and Foundation Trusts, although theoretically other providers are eligible to provide care.
Confused? I am not surprised, so are the experts.
Has childbirth changed?
The House of Commons Committee of public accounts in its report on Maternity Services in England 2013/2014 stated,
“There is confusion around the Department’s policy for maternity services, what it wants to achieve and who is accountable…
At local level it is unclear how commissioners are ensuring that maternity services meet the Department’s policy objectives or how they are holding trusts to account. Over a quarter of Trusts lacked a simple written service spec with their commissioners last year.”
Here we are in the 21st century. Two decades ago the Department of Health’s Changing Childbirth Report (1993) ensured that choice and control for women became government policy and the concept of woman centred care was introduced. In 2007 the policy document, Maternity Matters focussed on women being supported to have as normal a pregnancy and birth as possible. These policies among others, have led to many positive changes. Midwife led birth centres, caseload teams, waterbirths, etc.
What do women want?
In the light of this history we might expect that government policy would set out the broad parameters for maternity services with clinical commissioning groups commissioning the services that the women in their area need and want. Woman centred care, yes?
Well no actually. If you ask women what they would like, most respond that they would like easily accessible clinics with flexible hours, visits at home, care from the same small team of midwives throughout the pregnancy, birth and postnatal period and access to the acute NHS trust Hospital when needed. This sounds eminently sensible to me and is echoed by Louise Silverton of the RCM who has stated that she would like to see small local hub and spoke groups of midwives so that women can access care close to home.
Beverley Beech of AIMS has stated that she would like to all women provided with one to one care and 60% birthing at home or in an MLU.
Research by the federation of Women’s Institutes and the NCT found that barely a quarter of all women actually wanted to give birth in a hospital obstetric unit, with consultant led care. However 87% of women gave birth in this setting in 2012!
Small is beautiful?
So, despite all the evidence demonstrating that midwifery led, community based care is safer, improves outcomes and satisfaction and is cost effective, maternity services continue to be delivered and controlled by the “super units” the huge, complex, expensive acute NHS Trusts.
The financial structure of these organisations is now so complex that it becomes virtually impossible for services to be separated out and provided separately and where it is attempted, at the first sign of pressure those are the services which are closed or suspended. Just ask how often your local maternity unit has to suspend it’s home birth service or close the birth centre because the staff are needed elsewhere.
Dr Rod Jones, statistical adviser at Healthcare Analysis and Forecasting has said,
“I can’t see anything other than a larger unit or units linked together in such a way that staff can be rapidly shifted around from one to another…it’s simple economies of scale.”
Is it indeed Mr Jones?
When I was a sociology student many years ago I learned about the alienation of the workforce and the eventual damage to the economy from the factory style mass production evident in the “50s and “60s. On paper it looked massively cost effective but the subsequent damage to the workers was so great that they would do almost anything to break the grinding monotony and lack of control they experienced. What they usually did was to stage walk outs and strikes. Eventually the researchers discovered that by grouping staff into smaller groups who were responsible for making an entire product, productivity and satisfaction increased as did quality. End result, production methods changed for economic as well as humane reasons.
So where do we go from here?
Now here we are over half a century later and the economists are arguing that healthcare and the way we have our babies should be dictated by those very same outdated ideas. It leaves me speechless.
Somewhere in all this mess we must take a completely fresh look and recognise that the acute Trusts are simply providers, the same as any other provider of healthcare. Just because they have the monopoly at present does not mean that they should be dictating how maternity services are organised. Somehow the phrase “the NHS” has become synonymous with these mega organisations. But the Trusts are simply organisations who receive NHS money to provide NHS care and they seek to maximise their income or dare I say it “profit” just like any other provider.
So my message to all women, to CCG’s, policy makers, members of the Maternity Review is this…
Take a completely fresh look and build up a model from the bottom. Consider what women want, look at the evidence and offer smaller providers a chance to be a part of maternity services. Working alongside, but not under the control of the Trusts these providers can offer the hub and spoke model suggested and are woman centred, midwife led and cost effective.
You know it makes sense.
written by Tina Perridge