Freestanding Midwifery Led Units in Shropshire: at the sharp end of the debate

Notes from ‘Questions at the Shropshire CCG Board meeting’ 13th December 2016

Those who know me well will understand the commitment of turning out before 8am to drive somewhere (and back) on my own for the first time – I got lost with the help of two SATNAVs today but just managed to slip in on time to the Public Board Meeting of the Shropshire CCG.  I was there because the brilliant Gill George campaigner for the Ludlow Maternity Unit and small hospital had encouraged mothers and others to attend and ask questions:  she wanted a commitment from the CCGs to ensure their contract with the Shropshire and Telford Hospital Trust (SaTH) maintained the freestanding midwifery units (FMU) and all the maternity care they provide to local women in a large county.

The front row was taken by a cluster of Mums with their babes and toddlers – giving a dour meeting a lightness of touch and sense of humour that was much needed.

The first part of the meeting was questions from the public, and the first part of this (clearly planned) were questions from the Mums.  The first Mum stood up saying she represented a small fundraising charity for local midwifery units and all the Mums in the area as there were concerns that the maternity services at the Midwifery Led Units (MLUs) were going to be cut and indeed threatened.  They wanted the Midwifery units to be open 24/7 and offer the postnatal care and breastfeeding support they currently do.  SaTH have announced they will close the MLUs – of which there are three – Ludlow, Bridgnorth and Oswestry – at night, this will also end Postnatal stays and 24 hour breastfeeding support.

Her actual words were that the Units were going to be turned into Birthcentres – clearly implying this was a bad thing.  It is a shame that such a term in this area has become synonymous with cuts to the very services that Birthcentres represent to many of us in other parts of the country.

She described her own ordeal of being transferred by ambulance across Shropshire to hospital but not making it and having to give birth in a layby en route.  She believed that this would happen more often if the services of local MLUs were reduced so women had to travel significantly further during labour.  We know that the least safe place to birth is at the road side.

She described how in just a few days her Save Ludlow Maternity Unit Facebook page had got 1100 members and that there was a successful march in Ludlow on 3 rd December.

She gave 4 reasons for keeping the MLUs:

  • Research shows that most women labour during the night (Thank you Alison for that painstaking work over decades!)
  • Most Midwives live a significant distance from the MLUs, so there could be delays if women arrive in full labour at the unit before the on-call midwife can make an appearance.  And what if more than one woman births on the same night?
  • What would be the impact on breastfeeding rates if the units reduce their care?
  • Finally, she described how constant threats to the service and lack of investment in it reduced midwives’ morale.  Good midwives will leave the service was her message.

A second Mum stood and spoke.  She quoted the NICE  Intrapartum Care Guideline reminding the CCG board that planned birth for low risk women in an obstetric unit raised the rate of C-Sections in this group. That MLUs reduced instrumental delivery, raised normal birth rates and so on.

She also described the important role in breastfeeding the MLU in Bridgnorth had provided.  She described how they supported her breastfeeding and she only went home once she was confident.  She had found this invaluable.

Gill George then stood up and asked some incisive questions demonstrating she knew the politics and financial situation in detail.  She along with the Mums asked the board for the same thing:

We want the CCG to commit to funding for continuation of the current rural maternity service and units (Bridgnorth, Ludlow and Oswestry) and to get this written into their contract with the hospital trust – due to be signed by 23rd December. (We also want them to guarantee consultation before they allow any change to the service – but mostly we oppose the cuts!).

I always say that asking the question is more important than the answer you receive.  On this occasion it really was not the case.  The CCG iterated its position that safe good quality maternity services were a priority.  The dire financial position of the Hospital Trust and the CCG was stated but we were told that SaTH had not approached the CCG about reducing or changing its maternity structures. This was a significant point because SaTH have already announced that they are closing the MLUs at night in effect changing the service provision.

The speaker pointed out that there was an issue that women were choosing to birth at Hereford and have their postnatal care at Ludlow – but the tarrif money for the postnatal care had not been retrieved.  I recalled a similar difficulty between Calderdale and Bradford and decade or two ago!

Gill George pressed for rural maternity services to be in the contract signed on 23rd December and that there would be public consultation before any changes were made.  And what would be the chances of this being signed off on 23rd?  ‘Optimistic’ came the sad faced reply.

Here I am inserting Gill George’s notes of the answers to her questions at this point which she kindly sent to me on reading this blog:

Q: Will rural maternity services be in next year’s contract with SaTH (the hospital trust)?
A: Yes.
Q: At the current level of service?
A: We’re in discussions with SaTH.
Q: Are you expecting this to be possible?
A: I’m very optimistic.

This was from the Head Honcho of Shropshire Clinical Commissioning Group, in a meeting this morning. It’s possible that we’re getting there. We also got something that came very close to a clear commitment that would be consultation on any ‘substantive change’ to maternity services.

The floor was opened to further public questions – most of which were about cuts to services.  This is clearly a well rehearsed session with the players all knowing each other and their roles.  There is a sense of frustration from the public side as they fight to keep valued health services and exasperation on the board side desperately trying to balance books with one of the lowest budgets per head of population in the country.  There is a massive deficit and the prognosis is £15 million pounds worth of cuts to be found in 2017/18 by the CCG.  There was a short stunned silence at that point: there is no choice was the message we will have to cut valued services – there is no money.

The chair of the board said at one point to the public – you are the electorate you need to elect a Government that provides money for the NHS you want.  This said in a county that returns Conservative MPs and has the lowest financial settlement per head of population.

Finally I stood up and as light relief invited the board and everyone present to the SaTH supported conference – Implementing the National Review in Rural Areas:  Better Births in Shropshire and beyond #SaTHFMU

I mentioned its impressive speaker line up (including Baroness Cumberlege, Prof Dennis Walsh, Cathy Warick and Kathryn Gutteridge).  I left programmes on the table and the response was that someone from the board would probably be there.  Listening to the discussion it could be a good thing.  Here is the link if you want to join us:

Meanwhile in the foyer the local reporter was interviewing the Mums about what they said.  No opportunity wasted by these Mums to ensure the survival of their community maternity care.

A CCG with no money, with services costing more than their budget, a Hospital Trust with no money and running at a deficit (as are the majority of hospital trusts in England): the quality of all health services are threatened – A&E waiting times grow, dementia and other care is not getting the investment needed, Maternity care in rural areas threatened.  There are no easy choices here for the CCG Board and I would not be in their shoes for half of all England with no power but to dispense the national Government agenda of cutting heath service costs to this population – dressing it as efficiency does not wash.

In this context it can feel easier to cut low tech low cost services to protect the high cost, high tech, highly qualified services.  But as Alan Brace points out in my blog : Why is it so Difficult to Implement Continuity of Carer, it maybe the low cost services people actually need and it won’t save money to funnel more people into high cost services who only needed a low cost service.  This is the case with Maternity care in special degree – why send healthy young women across a vast county to birth in a high cost obstetric unit when they can more cheaply and safely birth at home or in a midwifery led unit? But if you have made a capital investment in a new Obstetric unit as SaTH has done – it has to be paid for by a higher throughput of women.  Read Belinda Phipps analysis in my blog: One to One Midwifery: How things can Change, of why Trusts may not save money by promoting midwifery led care.  In Austerity NHS, medical-based evidence may come second to a real terms reduction in NHS budget and whoever shouts loudest wins – so shout!

To support those campaigning locally for Shropshire MLUs join the Facebook group :

To join in a positive discussion about Freestanding Midwifery Led Units in rural areas and implementing the National Maternity Review for rural populations come to the fantastic Conference Chaired by Baroness Cumberlege 13th February for just £35 at the Shropshire Conference centre.  More info here:


Review of the "Celebrating Continuity, Rhetoric into Reality, Policy into Practice" Conference

The 13th April brought us “Celebrating Continuity, Rhetoric into Reality, Policy into Practice” a conference created through a collaboration between AIMS, RCM, The Positive Birth Movement, Neighbourhood Midwives and a Birmingham NHS Trust.

So many exciting themes came out of the conference, together with discussions of common concerns and their solutions.  One quote from Beverley Turner underlined the whole of the day, “Women should be utterly supported throughout birth, and never just “winging it with a stranger”.  I would equally say that midwives should be able to support women through birth having clearly understood their needs and wishes via a relationship built through pregnancy, and not left just “winging it with a stranger”.

An interesting comment from Baroness Julia Cumberledge, following a question by Ruth Weston of Aquabirths, addressed the frustration of so many campaigners that CCGs were unaccountable, even to Monitor.  She announced that she was working in a team which was developing a new framework which, if accepted, would give the power to evaluate CCGs and influence their practice.  This could be transformational for continuity campaigns where CCGs are refusing to implement what is safest, cheapest and gives the best outcomes for families.

There was an important reminder at this conference that maternity is not just about getting a baby out, but at it’s core, it’s building Healthy, Happy Families.  It was noted by Professor Lesley Page of the RCM that within caseload models of care, we see a reduced level of child protection intervention.  While child protection falls outside of the maternity tariff, and is therefore not considered as an outcome of good maternity care, it is likely that it means that continuity of carer under a caseloading model leads to better bonding between parents and their babies, and a stronger family into the future.

One fear raised by an audience member was that midwives would be on call for weeks on end, and that was unsustainable, and indeed this is a concern that worries many.  The response given was that there are many necessary models of midwifery, and there is space for all needs, including shift work and midwifery teams.  Indeed, it was pointed out that fragmented, busy labour wards where midwives can’t take a break is leading to midwifery burnout all over the country, not only with our qualified midwives, but the trainees, too, as shown in this heartwrenching Facebook post which went viral recently.

A combination of talks and workshops, this event was hugely informative and inspirational.  Looking for positive ways to work on the implementation of continuity and caseloading, addressing the concerns and questions that came up, and reinforcing the message of support for each other.  A fantastic day with fantastic people, the conversations are continuing and the changes will happen!

Twitter: #continuity2016

Report by Emma Ashworth