Recently the National Maternity Review was published with recommendations as to how maternity services should change over the next five years, with proposals designed to make care safer and give women greater control and more choice.
The most headline grabbing aspect of NHS England’s report are plans to offer pregnant women their own personal budgets, worth at least £3000, so they can pick and choose the care they receive.
Whilst I don’t doubt the merits of giving women more say about how and where they give birth, I question how workable the plans are in practice. Who’s going to allocate these funds, provide them, manage them, and fund the shortfall when things go wrong? Most importantly will this do anything to drive up standards of care and improve patient safety?
The report found that the number of stillbirths and deaths soon after birth have fallen by over a fifth in the last decade. This is welcome news but given the report found that in half of all stillbirths there are elements of care that if improved, could have made a difference, and that the NHS spends £560m each year on clinical negligence cases relating to maternity care, clearly there is a need for considerable improvement.
As a legal practitioner who sees the impact poor care can have first hand, I am concerned about the proposals. They encourage women to consider home births, or births in community midwifery centres. There is some research into how safe a home birth is and the potential dangers, with The Birthplace Study finding that they are riskier than hospital birth for those having their first child but carry no extra risk for those having a second or subsequent child for whom there are some benefits. Certainly in my experience, the reality is that if a mother experiences complications during birth, the situation can change critically in a short space of time – being in close proximity to a hospital obstetric unit will give access to medical intervention sooner. How will women weigh up the risks and come to a decision and will practitioners be under pressure to push them toward cheaper alternatives?
For some women, added choice will bring added worry – will they have the information at hand to make choices? What will they be opting in and out of given the current care that is provided (blood tests, scans etc.) is all considered necessary for the safety of women and their child? Will we see a cash strapped NHS pushing them towards cheaper options? The devil will be in the detail but one concern is that those who are more informed and perhaps more articulate will be better able to navigate the system and push for more services whilst the rest are left behind.
One of the findings of the report was the importance of continuity. Women need joined up care and the report has stated that every woman should have an allocated midwife who is part of a small team. This kind of continuity is important for standards of care – fragmented care is a known risk factor in maternity cases with poor communication and a lack of cohesive care resulting in problems being missed or women being unsure of where to go for help.
The plan for personal budgets, however brings with it the risk that care will become even more fragmented. If the £3,000 is to be spent within the NHS, commissioners have to consider ‘any providers’ bid for NHS contracts. This may well open the way for private companies to provide services, potentially cherry picking more the straightforward services with the potential that when complications arise the NHS will be expected to step in. Having a mix of different providers, including those within the private sector will inevitably mean less continuity.
As a wish list of how maternity care can be improved, the review is welcome and no one can dispute that more detailed personal care plans, greater continuity from midwives and heightened awareness of maternal mental health would all improve care. The question is whether at a time when the NHS is struggling to cope with increasing demands, a shortage of midwives and nurses and pressure to cut costs, a shake-up of maternity services is the best remedy for poor care standards. Rather than opening care up to potentially more private providers, decreasing continuity and creating a system of choice that could see greater inequality of care, I would like to see the NHS focusing on providing full, well-resourced local maternity services to all women. Choice should not be a panacea for poor care; the NHS should be focusing efforts on learning lessons from past failures in care and developing best practice across the board.