How to Commission a Homebirth Serivce – by a CCG Commissioner

Notes from 2nd July NCT Birthplace conference, Birmingham Medical School

Diane Reeves Accounting Officer for Birmingham South Central CCG:

Commissioning a Homebirth Service

These are a mixture of my notes of the presentation pulling points from the power point slides. I have labelled my comments clearly and where I have lifted slides the extra speaker comments are in italics from my notes. Italics can also denote my interpretation of what was said.

For the full slide presentation and recording go to: http://www.nct.org.uk/professional/events

Personal story –She was present at the birth of her sister in 1965, and 3 years later with her younger sister she ‘giggled’ through the birth of her brother. Diane is a GP by profession and has 4 children. Three were born at home, one against medical advice.

Comment: in her talk this experience and understanding clearly influenced her work as a clinician in this area and she was open about the fact that it had. She said that she convinced her peers with medical evidence, but her personal experience was what kept this as a priority and kept her pushing with her CCG colleagues. It also helped that her Commissioner colleague for maternity services at the CCG was a GP who, along with her siblings, had been born at home. They both felt that peer to peer discussion was what worked in pulling this off.

It was clear from Diane’s presentation, her colleague the commissioner in the audience and the senior Clinician speaker earlier in the day that there had been a number of them convinced of the need, and wanting to set up, a homebirth service in Birmingham, however, the barriers had been too great until now.

Key barriers were:

  • Finance and tariff issues- introduction of more granular tariff
  • Lack of published evidence-Birthplace study endorsed the safety- published 2011 BMJ
  • Interaction of evidence with clinical commissioning – lack of pathway from evidence to implementation. Need for leadership.
  • Increasing population, young city, high birth rates- links to capacity – easier to do more of the same?
  • Under-used home birth service because not dedicated – on call midwives pulled into labour ward leading to patients not satisfied (promised service not happening). Not promoted as a result.

GPs were also wary and unconvinced about having such a service:

What were the GPs concerns about the service?

GP HB survey findings

GP survey circulated in July 2013

42 surveys completed

Main concerns:

  • Medications •Attendance – •Transfers •New baby checks

Comment: Key concern seemed to be that they would be landed with situations beyond their competency: they would be called out to a birth or be involved in night transfers. Thought they would have to do the baby checks – but midwives can do it. Worried be responsible if things went wrong when they had no control over it. Clear that most GPs had little expertise in this area and were unaware of latest research on homebirth and other research findings.

W hat made it succeed:

  1. A cross section of convinced and committed professionals pushing for it over a long period of time. Doctors, midwives, women.
  2. Peer to peer advocacy important.
  3. Building sustainability in terms of finance and numbers is important right from the start – the service had to work on the Maternity tarrif alone – this has been a problem with past projects.

What made it happen? Key success factors

  • Evidence, data, choice and capacity issues creating a mandate – ie the combination of the medical evidence, the choice agenda in public health policy and the hospital capacity issue – too many babies being born for the Obstetric Unit to cope with.
  • Enthusiastic provider team (MWs and OBs), enthusiastic (female) GP commissioners- with a desire to improve choice and reduce interventions for low risk women.
  • Non recurrent spending requirements- initial pump priming . To get the results and the savings long term initial investment has to be made.
  • Work to promote it to GPs- educational events, GP networks Peer to peer education seemed to be key.
  • MSLC support – the MSLC kept raising this issue over years ( I get the impression that they were fed up of raising it by the end) but it kept it on the agenda until all the elements were in place
  • “Big social conversation” engagement events- reaching diverse communities (but BSC patients only at present) Community participation not a top down approach (more of this in another presentation)

I would add strong leadership from CCG Commissioners – who were female, mothers and had personal experience of homebirth. It is a strategic thing.

Commissioning for Quality

  • Intra-partum transfer review and benchmarking – ensuring that transfer rates do not exceed the Birthplace average
  • Continuity of care is important: 3 or fewer midwives through whole package of care. Another presentation by the head of the HB team said that they decided not to do 121 midwifery but team care due to staff lifestyle balance – but the standard is that women meet 3 or fewer midwives during the entire pathway.
  • Breastfeeding rates 75% – high BF rate is expected and delivered
  • Incident reporting and monitoring – this has to be as rigorous as in a unit
  • Diversity of users – not just for hippies

Diane showed a video of an interview with South Asian couple. They could not understand this thing about being given toast after the birth. She said ‘Why am I being given warm bread? Is it some kind of ritual?’ Remembering the cultural aspects of communication and birth!

Sustainability and where they are at: 240 births is the breakeven point for sustainability and in their first year they are on target to meet this point within three years. For equity however the HB team needs to be rolled out across Birmingham. Also, HB team in first year – none of the GP concerns have been realised!!!

Message to everyone out there:

  • Build sustainability into your business plan
  • Strong cross professional leadership needed. Key here was GP leadership.
  • If it fails this time around keep pushing: its time will come.

Watching choice disappear

It was only about eight weeks ago that I was writing up good news. NICE (The National Institute for Health and Care Excellence) confirmed that it’s safer for around half of women to give birth at home or in a midwife led unit.
Hooray, we thought… the evidence is out there, the cautious and well respected NICE is reinforcing the benefits and better outcomes found in a natural birth.
Yet…
Since then, Calderdale Hospital Trust has failed to renew their consultant midwife’s contract and closed the long standing birth centre “temporarily” due to sickness rates. Also, the MAMs service in Airedale is shutting (this is breaking news so we have few details yet). And GPs have been sent a letter scaring them with unfounded concerns about local midwifery service 1-2-1, leading many to refuse to refer women wanting to use their services.
The debate about the guidelines was how we could increase access to natural birth to let everyone have the chance. But here in Yorkshire right now, women are being left without choices, without certainty and with the higher risks associated with hospital births: more interventions, much higher chances of a C-section, stressful environments that interrupt Oxytocin production and so on.
There are many complex reasons why any of these things are happening, but what I think links them is a clear lack of commitment to natural birth in commissioning, despite the guidelines.
Natural birth services are being seen as an ‘add on’ that can be dropped, because they aren’t closing labour wards! So can we hold commissioners to the guidelines? While health professionals get to make the final decision, “Healthcare and other professionals in the NHS are expected to take our clinical guidelines fully into account when exercising their professional judgement.” (NICE website) Therefore, we can argue that they aren’t taking guidelines fully into account if that’s what we believe, but we don’t have the right to overrule the commissioning judgement automatically.
When the future’s uncertain, one of the best things we can do is to keep sharing our experiences. The other thing we can all do is “ROAR”, as Sheena Byrom puts it. We’re organising petitions to make sure the health professionals making these decisions know that we care what happens to women during a very vulnerable experience. Here’s the link to the Calderdale petition.
Things we start to take for granted can disappear if we don’t roar.