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Government Policy
Government policy | The wider health context of maternity care | National Issues
Government Policy
Government policy now supports the use of birth centres in bringing care into the community. By providing care in this way, it will be more accessible to a wider range of people. Having a baby is a normal life event and so there is no need to visit hospitals or doctors if all is going well. Women should have the choice of staying in an environment in which they are comfortable, being cared for by the lead professionals which for low-risk women are midwives whose specialty is normality.
All recent DH guidance has stressed the need to balance three principles:
*Provide a patient led service
* Provide a high quality service
*Provide a service that is value for money
When planning maternity services, service users should be at the forefront of consultation to ensure appropriate services are commissioned. Developing a wider selection of providers gives more freedom to staff as well as patients. Providing a framework of system management, regulation and decision making which guarantees safety, quality, equity and value for money is central to the service of the NHS and the a principle wholly endorsed by Maternal Link.
Money follows the patient through PBR to reward the best and most efficient providers which gives others the incentive to improve.
The aim is to improve the health and well-being of the population, reduce inequalities and social exclusion. The Department of Health wants to improve the quality, effectiveness and efficiency of services. By increasing choice for patients a better experience will be provided through greater responsiveness to people’s needs. Last but not least the aim is to achieve best value within the resources provided.
Click here to read an overview of Government Maternity Policy in the last few years showing growing commitment to the improvement of maternity care along the lines which Maternal Link proposes.
The wider health context of maternity care
Good maternity care has life long health benefits. By improving maternity care, which will involve a financial investment now, the burden on the NHS will be reduced in the future. The following table extracts from ‘Modernising Maternity Care’ (DH, 2006) to show how maternity care contributes to the Public Service Agreement (PSA) targets.
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The above summary table can be substantiated from the very extensive research gathered on the Primal Health website and others. Maternal Link believes women should have access to a balance of information around their care so that they can take an informed choice.
The guidelines and research quoted above show that there is both a political will and clinical need for change in maternity services. The necessary change in service provision has been identified as has the process to achieve higher quality and greater value for money. However, there remains a gap in many areas between government policy and local action. Maternal Link aims to help commissioners fulfil the government’s aims in a financially viable and sustainable fashion.
National Issues
Staff | Funding | Maternity Units | Impact on Care
Problems in maternity care vary around the country. Some areas suffer a lack of staff, some a lack of facilities, some a lack of managerial will power. All areas suffer a lack of funding; funding for maternity services has shrunk from 4% of the total NHS budget in 2000 to 2.6% in 2007.
Staff
There is a shortage of hospital midwives across much of South England, particularly in city hospitals where agency midwives provide the bulk of midwifery staff. Approximately 60,000 qualified midwives in the UK choose not to work primarily due to poor working conditions resulting in low job-satisfaction. Research has found that the decision to leave midwifery is not taken lightly and so recruiting staff back into the profession would be a long and difficult procedure. Within the next five years approximately one third of the remaining midwifery work force will retire. The staff shortage is set to get worse nationally.
“This analysis painted a depressing picture of a group of very committed professional women, struggling over a protracted period of time, within an environment of increasing confrontation and stress.” Kirkham, M; Ball, L; Curtis, P; (2003) Why Do Midwives Leave?
Talking to Managers In Kirkham’s 2003 study ‘Why do Midwives Leave?’ the challenges facing midwives in existing establishments, i.e. hospitals, were shown to be so ingrained that it would not be possible to change the working environment enough to bring midwives back to work.
“If, as managers suggested, the issues that fuel midwives’ decisions to leave midwifery are not amenable to fundamental change within the current establishments, then a radical reconsideration of staffing levels, in the light of changing levels of client dependencies, is urgently required”. Kirkham, M; Ball, L; Curtis, P; (2003) Why Do Midwives Leave? Talking to Managers.
Maternal Link’s understanding from the published research is that it will be difficult to bring midwives back into practice in hospital environments; their preference is for midwifery led birth centres which would give them much greater autonomy to practice woman-centred care.
Empowering midwives was also important in the findings of Kirkham. Midwives, often married women with families, need to feel in control of their work so that they can fit it around family commitments which means running a different style of care to a traditional hospital shift pattern.
“… working hours should accommodate their caring responsibilities. The majority of potential returnees identified the need to be provided with effective, adequately resourced support appropriate to the needs of the individual… Encouraging return to practice will require employers to enable more flexible patterns of working…Such a change, while necessary, may not be sufficient to attract midwives back into practice in appreciable numbers.” Kirkham, M; Ball, L; Curtis, P; (2003) Why Do Midwives Leave? Talking to Managers
The style of working sought by many midwives is not compatible with a hospital style of working which is based on shift systems and clinical rotation preventing midwives developing a relationship with the women they are caring for. Birth centres show a clear differentiation in style of work, philosophy of working environment and, under Maternal Link’s plans, put midwives at the centre of the planning and management process.
Therefore, Maternal Link aims to create a working environment that is attractive to midwives, both newly trained and those who may consider returning to practice. Using support staff including Maternity Care Assistants (MCAs), housekeepers and administrators Maternal Link will encourage midwives to focus purely on midwifery work providing a more efficient system and better use of resources than exists in much of the NHS at the moment.
Maternal Link acknowledges that not all midwives will come flooding back into practice, however it is important that a sustainable model of midwifery is put in place to recruit and retain midwives so that as the remaining workforce retires recent changes do not collapse.
Funding
NHS maternity care has been paid for by block grants which vary around the country and are usually based on historic figures and ability of individual negotiators. There is a wide variation in the level of service provided for block grants. Available data to date, being gathered for PBR purposes seems to be showing that activity levels have been seriously underestimated in maternity block grant negotiations. Funding in real terms has been reduced in the past decade (from 4% of total NHS spending in 2000 to 2.6% in 2007) even though there has been a funding increase across the NHS.
In many hospital trusts, obstetric and gynaecological care is intertwined financially, and the sub-budget for maternity often includes the community services as well as hospital services. Because all these services are included in the same block funding, community midwifery care given to low risk women is effectively subsidising the costs of treating high risk women where consultant’s skills are required.
Information is currently being gathered to set an accurate community PBR tariff. There is usually limited data recording the work of midwives or their activity levels, particularly those operating in the community. Therefore, a Finance Director of a trust may have a completely different financial view of maternity services from a Head of Midwifery.
Maternal Link would facilitate significantly better data collection, data analysis and cost efficient care both through better trained staff and a more accessible model of care that would not result in hospital admittance for what are, essentially, routine check-ups.
Maternity Units
Around the country there are insufficient alternatives to an NHS hospital birth. In some places there is either an NHS alongside birth centre or an NHS stand alone birth centre. Some areas have a private hospital, private birth centre or Independent Midwives. There is immense inequality in service provision and in many areas there is no alternative to a hospital birth or very limited assistance for a home birth. Throughout the country the pattern of encouraging women to give birth in a hospital remains the norm. This trend has primarily been insurance driven.
Staff and finance shortages have been reducing community midwifery and over stretching hospitals. This pressure has increased the demand on women to conform to hospital protocols which generally aim to speed up the process of birth and restrict staff time with women. This has led to increased intervention rates during birth and reduced quantity and quality of postnatal support. The plethora of complications and pressures the hospital environment causes maybe unintentional but are no less real.
Maternal Link aims to develop a network of birth centres promoting a uniform approach to midwifery on a national scale. Maternal Link believes the concept of birth centres is now well known and researched and so pilots are to develop Maternal Link’s business proposal, not the overall concept of birth centre care. Maternal Link aims to develop five pilots over the next two years and then a national roll-out can take place with relative speed. To achieve this, Maternal Link needs the support of midwives and the public to engage commissioners in the process of changing maternity care.
Impact on Care
The national caesarean-section rate was 25% in 2006 and has been rising at approximately 2% per annum for many years. The corresponding fall in midwives and thus quality of care is leading to an increasing number of litigants and complainants, raising the issue of traumatised women and the long term health implications for their children.
Maternal Link aims to:
* increase the number of working midwives which will provide a model of care that will improve safety and quality
*create an environment that will promote a holistic approach to the health and well being of women and their families around the time of pregnancy and birth
* promote knowledge and education to help women and their partners prepare for parenthood in a responsible and informed manner
* focus on the wider ramifications of having a child, beyond the limitations of a medical
model of maternity care
This approach will over time reduce the burden of poor health and thus cost on the NHS. By improving knowledge as well as health outcomes around maternity the long term health of the population will be improved.