Belinda Phipps CEO of the biggest UK wide charity for parents NCT sets out the barriers to achieving one to one midwifery care on the NHS and how it can change to enable the maternity care we all want.
The question is: why is it proving so difficult for CCGs and Providers to deliver one to one care, and why is there so much opposition to commissioning other providers to deliver the care?
In addition to the answer given below she has offered to work with CCG commissioners here and in other parts of the country because she says there are ways and means of working within the NHS rules, inappropriate as they are at the moment, to give acute hospital providers the flexibility they need to deliver one to one/personalised, continuity of CARER.
Belinda Phipps, CEO of NCT over to you:
I think you know that it is proving difficult for the NHS itself to offer or to buy in proper one to one care with a midwife you know and trust because
1) The health service including commissioners don’t accept/understand how important continuity of carer is to women and what health benefit/cost reductions this can bring over all to the NHS. If you want to help them understand add your voice to this campaign http://www.m4m.org.uk/
2) The heath service cannot, with in its current system rules accommodate case-loading in a sustainable way that is acceptable to most midwives
3) Fairness is an important NHS value and a service that is “unfairly” better and reaches only a minority of women is difficult for commissioners to take on.
I think first we need to change NHS rules:-
In England the new risk based PbR (Payment by Results) will not work any better than the old activity based one. We need a system that is truly based on results ie outcomes for the woman and her baby. We need to pay when women are satisfied with their care and when babies and mothers come through pregnancy and labour whole and healthy with the mother feeling ready to start her role as mother.
The old PbR (Payment by Results) system paid by activity. The more activity you did as a hospital, the more you got paid, the more complex activity you did the more you got paid. It was based on the principle that C-Section costs more than a normal birth so the payment for this would be higher, using the principle that the price of an activity is the same as costs, because the NHS is non profit making. However the actual cost of a C-section for instance is not known and the payment for it does not necessarily bear any resemblance to what the procedure actually costs in reality.
However, in reality, in an Acute Trust 85% of costs are fixed which means that a per treatment cost as above does not work because the building, equipment and staff need to be available even if the C-Section is not done. So there maybe little difference in cost for a Trust between a 15% C Section rate and 25% C- Section rate in terms of costs to them. But they rely on the income often to fund the fixed costs for other services and so any fall in the election rate means they cannot cut costs because so much of it is fixed so start to have financial problems
This means a ratchet mechanism operates which drives the C-section rate up irrespective of clinical need.
The new PbR system allocates women at booking to a risk category ( low medium and high) of course there is now an incentive in monetary terms to allocate women to a higher risk category to raise income levels delivering more women into the Consultant led system.
What would work is a payment of x per birth ( where x is total cost of maternity in UK minus necessary admin costs not borne by providers divided by number of births) with a deprivation payment per woman for those from the most deprived postcodes ( bit like the pupil premium). This should be paid per birth and the provider take the risk. Effective providers would benefit by making sure they did all the preventative work they could to keep births simple. There would have to be a rule that says the woman chooses the midwife and then irrespective the provider cannot refuse care (they would have to pay for others to provide complex care if that became necessary). However this would require the NHS to break its mental rule of cost=price at a treatment level.
This would also work better than the block contract approach.
Another option is to give the woman the budget – and I like that option too.
In concert with this, the capital changes have to be changed from a charge on space (as now) to a charge on people (a capitation charge) so the payment has to be made irrespective of treatment location which would remove the drive to treat people inside buildings in acute trusts unless this was clinically necessary.
You know I think CNST (the NHS litigation insurance payment system) and its equivalents in other countries needs to change so that prevention and watchful waiting is rewarded with lower fees and that the focus is not only on being safe during intervention however necessary or unnecessary they are.
Then there is the whole business of care being carried out in organizations where the governance and the building is aligned. They don’t need to be and a system set up across trusts with the service and governance alighted rather like clinical networks with teeth would probably work better, certainly for maternity.
Case-loading without the rule changes above is only a partial solution to this dilemma and is difficult to sustain because of the above.
It starts to address this problem of women being left alone in labour and stressed midwives caring for may women because the rostering pattern almost never matches the number of women in labour. It can’t be done like this, so the system needs changing.
I am happy to offer whatever support I can though I think NCTs optimum skill is getting attention paid to these rules so they change for the better and make it possible for women to have a midwife they can get to know and trust who is there fore the pregnancy, labour and birth and afterwards. if you want to help join us http://www.nct.org.uk/get-involved/become-nct-member
And don’t forget the Airedale Mums Petition for One to One Midwifery http://www.thepetitionsite.com/593/491/398/support-one-to-one-midwifery-care-for-the-women-of-bradford-and-airedale/