Guest post and Q&A: "The National Maternity Review ushers in a new era of care"

[MumsnetGuestPosts]

This week I launched Better Births, my team's report into maternity services in England. This report marks the culmination of 12 months' work reviewing current services and developing ways that they can be delivered better, for the benefit of all mothers, babies and their families.

The report lays out a series of recommendations which will make maternity services safer, more personal, kinder, professional and more family friendly. You may have already read about the personal maternity care budgets in the news. These will give women more choice, empowering them to spend NHS money on the NHS services which suit them. This is only one of the report's many recommendations, but I am looking forward to answering your questions in the comment thread below this post from 11am to 12pm on Wednesday 24th.

It has been a mammoth effort, and we couldn't have achieved it without the amazing support we received from mothers up and down the country, who have made so many vital contributions to the Review.

During the course of the Review we heard many heart-warming stories, but there have also been harrowing reports of when things have gone wrong. I am enduringly grateful to the women who have shared their experiences with us. In many cases it has taken great bravery and your contributions have been vital to our work improving maternity services.

Having heard from women, families, midwives, doctors and other service providers, we know that there is some excellent care in England but we also know there is significant variation and we could do better.

Women told us that they want to be able to make choices based on unbiased information and for their opinions and decisions to be respected. Better Births recommends that every woman should have a personal care plan developed by her and her midwife, built on her decisions, and informed by an assessment of the type of care she might need. This will put women, babies and their families at the centre of the care they receive.

We believe there should be more continuity of carer so that women can build a relationship of mutual trust and respect with their midwife. Under our recommendations, every woman will have a dedicated small team of midwives providing care throughout their pregnancy, allowing women to develop a rapport with their midwives and for their midwives to have an ongoing understanding and appreciation for the needs and wishes of the women in their care. Women will feel more supported and their pregnancy will be safer.

Our Review found that professionals don't always work together as well as they could. The Better Births recommendations will break down the barriers between midwives, obstetricians and other professionals to deliver multi-professional, safe and personalised care to women and their babies. This will be aided by better training, establishing the principle that professionals who work together train together. Working together across boundaries, professionals will ensure rapid referral and access to the right care in the right place. We will instil a safety culture within and across organisations, and will ensure that there is timely investigation, honesty and learning when things go wrong.

Women told us that they wanted better, more convenient access to maternity services so we are recommending that more services are delivered in the community. We aim to improve access to services and ensure that rapid referral to more specialist care is available when needed.

There is still much to do in ensuring that the recommendations of Better Births are effectively implemented across the country, but women throughout England have every reason to be optimistic. The publication of this report is truly exciting. It ushers in a new era of maternity care which will make services in England among the best in the world.

The report demonstrates what we've learnt and begins to bring into reality, across the country, our recommendations for the benefit of women and their families. We will ensure our recommendations are delivered sustainably now and in the long term, so that future generations will benefit from maternity services that are among the best in the world, putting the woman, her baby and family at the centre of care.

Knowing that this report will shape how maternity services are delivered in the UK for many years to come fills me with great excitement. I want to thank all the mothers, families and healthcare providers who have taken the time to provide us with their invaluable insights into maternity services and how they feel they can be improved. I especially want to take this opportunity to thank all the Mumsnetters who have contributed to this Review, and whose passion and insight have made the process so rewarding. Without the contributions of thousands of individuals up and down the country this Review could never have happened.

[WhoTheFuckIsSimon]

I'm a midwife and have read the report today. Sadly I'm at work tomorrow. I totally agree with the main thrust of the review but I do think a lot of it such as personalised care is already been done. The thing I picked up on was the recommendation for team midwifery similar to the service on The Wirral.

Nationally we've been there and done that in the past, it's more expensive and requires more midwives. How can this be funded? Do you think the govt will act on your recommendations and will there be a move back to team midwifery?

[MilkOfAmnesia]

Good evening,
I'm one of the other Health care professionals an expectant mother may come into contact with. I have to say, I'm very much in agreement with Simon. There are some good recommendations in this report, but without a huge injection of cash and many more midwives, it just seems 'pie in the sky'.
I also can't shake the feeling that there's a trapdoor to privatisation hidden somewhere. But I'm a very cynical and pessimistic person of late junior doctors.

[WhoTheFuckIsSimon]

Yes privatisation also flashed up in my mind When I read this. I believe One to
One on the Wirral is a private company which delivers a service just like the one recommended in the review.

[pullthecracker]

I'm a midwife also. We DO offer choice for place of birth, we DO give women options for where they have their antenatal care, we DO see them for most appointments antenatally (except for sickness or annual leave), we DO care for them in home births, and we DO see the same women postnatally.
What exactly are you changing?

[SunIsShiningWeatherIsSweet]

I love the idea of more consistent care. I saw a different midwife almost every time antenatally and for the birth and again afterwards. During the birth I had 3 different midwives due to shift changes at MLU, 1 new midwife for an emergency transfer (I cannot believe that they threw me in an ambulance with a midwife I'd met literally being wheeled to the ambulance) and then another midwife at hospital. I'd never met any of those midwives before that day and never saw any of them again after the birth. It was a distressing time and meeting all these new midwives was equally distressing as each would have a different opinion on things, a different way of doing things or simply a different way of supporting. I found this very confusing and it made me very anxious. As I never saw any of them again afterwards there was no one who was there who could explain what had happened. Do Trusts have to follow the recommendations or are they just guidelines? How long do you think it will take to make this change? I can't explain how much I hope they bring this into my local maternity services!

[PausingFlatly]

Baroness Cumberlege, you are a Tory peer who went on the record as long ago as 2000 stating that you are ideologically opposed to a fully state-funded NHS, and want to introduce a highly complex "NHS insurance premium":

"I would suggest that we should all pay, each according to his means, an NHS insurance premium, with everybody paying something so that all are enfranchised. The NHS will then compete against all comers. It should, like so many industries, have a regulator or an inspector, as we have for schools, enforcing standards, insisting on efficiency, dedicated to quality, owned by the people and at arm's length from politicians. The Commission for Health Improvement goes a little way towards meeting that requirement.

"The NHS premium payment would be set, like the BBC licence fee, with some political involvement. Everyone with insufficient income would have their premium topped up from general taxation. Of course this is called "means testing", but then general taxation, which now pays for the NHS, is means tested. We should not be fearful. It would be an insurance payment which everyone understood."

"Income tax could fall, allowances could be made for those with private insurance and private expertise could be used."

Baroness Cumberlege, Hansard 2 Feb 2000


Nice that you're calling it insurance, too.

I was glad to pay into National Insurance, because I believed the promises that were made of adequate (not generous) sick pay, should I ever be unlucky enough to need it. I'm now disabled and have been at the sharp end of the cuts, and of the immense bureaucracy and incompetence of ATOS and the DWP doing their absolute damnedest to avoid paying out the Incapacity Benefit/ESA I paid my NI for.

What was that again about we shouldn't be fearful?

[PausingFlatly]

By the bye, in the same 2000 speech you patronisingly state that we plebs "are totally unconcerned with organisational structures, just as they are disinterested in the management of, say, Tesco, where they want a quality product at a price they can afford."

So the concept of the ethical consumer is a new one on you, then?

The decades-long boycotts of Nestle because of unethical baby-milk sales passed you by? Boycotts of Tesco because of unethical use of workfare, also a bit of mystery? Successful campaigns for higher animal welfare? Against sweated labour in garment factories?

We citizens of this country have a long history of caring about a lot more than the superficial "product" slapped in front of us.

It's not really a sign of listening to what women (and men) want, to claim otherwise.

[PMHull]

So many cases of death and injury during childbirth are directly attributable to a caesarean carried out too late or not at all, and yet the undeniable life-saving, prophylactic benefits of a planned caesarean don't warrant a single mention in this review.

The push for natural/normal birth at all costs, and the drive to reduce caesarean rates to arbitrary levels continues to endanger the lives and quality of lives of mothers and babies. This review cites cost savings with fewer medical interventions, but appears to forget the colossal litigation bills this country pays out (and still owes) to families when the avoidance of caesarean birth leads to death and injury.

[PMHull]

If permitted to add, see three posts published on Feb 23:
cesareandebate.blogspot.com
Thank you

[icklekid]

pullthecracker I'm also dubious of the report however perhaps part if the point is the variety in care across the country. It's great for women you work with to get the choices you mention but it has not been the case for me and other women in different locations.

[April2013]

I understand a lot of women want the same midwife but tbh I think it is safer dealing with many different ones as you are then given access to a variety of opinions\ideas\experiences which I think is much better than just those of one or a few. Plus it is better to briefly meet one that doesn't seem to be offering a great standard of care than to have that midwife throughout or for a long period until you manage to change, same goes for all health professionals.

Was this board asked for contributions to this report? If not it seems a bit rich that this Tory is now only seeking feedback once it has been written and published and makes me think it is likely to therefore be very biased towards a particular agenda rather than simply trying to make maternity services safer.

Is there any mention of additional doppler scans in the third trimester?

[April2013]

...can't find anything about additional scans in third trimester.

I am disappointed this report is not focussed on specific, practical measures that would reduce still births and premature births. How exactly are they wanting to improve care around IUGR, reduced movements?

[pullthecracker]

icklekid that's true, so then work should be put into those individual trusts that aren't able to offer it rather than basically privatising midwifery and reducing women's choice, and giving them more stress by asking them to pick what care they want.

[WhoTheFuckIsSimon]

Everyone was asked for opinions/to contribute to the report. It was publicised on here and anyone could go to the website and write stuff.

I'm also disappointed that apart from this 3k budget and recommending some form of team midwifery that there's no specific recommendations......or at least nothing which isn't already being done.

[WhoTheFuckIsSimon]

sunisshining I don't think IT would ever ben possible or indeed safe to have the continuity of care where the same midwife stays with you for three shifts. I for one would leave midwifery if I was expected to work three shifts straight so a women didn't have to have a different midwife in labour. It would be physically and mentally impossible. I currently don't feel safe to the end of a busy long 13 hour shift and much prefer shorter 8 hour shifts.

[JugglingFromHereToThere]

Good morning Julia, your introductionary post seems very encouraging and I'm also hopeful that the proposed changes will represent increased resourcing for maternity services in this country generally.
In particular I hope that better care will mean fewer still-births in the UK as I know more than one person who has suffered this tragedy.

I think birth is such an important time for women and their families and that getting this more right for more women is an excellent and long overdue use of our resources.

I was fortunate to have two good births including one where I was able to use a water-pool throughout. The care I received was good too although like many I see areas for improvement, especially in terms of continuity of care and the post-natal ward.

Most of all I now have a teenage DD and I hope if one day she has a baby that her experience can be even better than mine was.

My question .... I didn't have the opportunity to contribute directly to the review but have contributed my experiences and ideas to many pregnancy and birth threads on Mumsnet over the years.
I just wondered if you and your colleagues working on this review have been reading relevant threads here on Mumsnet at all?
It would be good to feel that our voices have been heard

[RedToothBrush]

The care I received during my pregnancy was in probably the very model of what every woman should receive. I was listen to. I was able to choose a hospital out of area (including a referral to a particular consultant midwife), additional mental health support and eventually an ELCS for mental health reasons without hassle.

I am exceptional happy to see the extent to which mental health is in the report as it is long overdue and my experience is not the norm sadly.

However I am exceptional worried by a number of things in the report and the way in which it has been reported.

The report gives the distinct impression that choices now are not available and the payment system will magically make those choices possible. The emphasis that the payments system will be the key to change is one that I find troubling and misleading in many ways.

The Maternity Review was commissioned of the back of the Morecambe Bay problems and concerns over safety. There is a surprising lack of talk of health and of the safety of women in the press coverage. Indeed I think there is a real danger in thinking that the review has been used an opportunity to encourage privatisation style idea rather than be concerned about women's health. I think the idea of 'choice' being the way to improve safety is potentially disingenuous. Many of these choices already exist and are available and the tone of the report is to suggest that certain things that should be available as standard care will now be regarded as 'extras' or the result of 'demanding' women wanting luxury rather than basic care appropriate for their personal circumstances.

The idea that personal budgets will drive social change and wider public attitudes is naïve and gives women a false impression.

I appreciate that I have a long list of concerns, and don't expect there will be time for them all, but any answers would be great and any others be considered during implementation.

My ELCS was for mental health and this was strongly stressed to be as being 'clinical need' by all my HCP. However my paperwork stated maternal request. It also means in the current culture that hospitals are able to adopt policies that 'ban maternal request ELCS' despite the NICE guidelines.
a) Will there be a forced change to reflect ELCS for mental health reasons as this has implications for funding.

When I was trying to choose my hospital because of these 'bans' on 'maternal requests' I was keen to find a hospital with a favourable attitude to ELCS. What I found was hospitals do not publish their standard policies on this and similar issues. This is a major handicap to ultimate 'choice' as its like choosing blind fold. This also encourages disparity in care. The only alternative to this, is to force hospitals to abandon individual policies and make them all adhere to NICE guidelines to the letter.
b) Will hospitals be forced to publish policy in areas where women make most choices or will they forced to adhere to NICE guidelines to ensure transparency and/or ensure consistency of care

I understand that mental health care will be funded by a separate pot of money. However despite choosing my own options, I worry about the implications of choice backed by a budget for those with similar problems. I was in a privileged position and able to make choices others would not be able to.
c) How will you ensure that vulnerable groups are not getting the 'left overs' of choice and that they don't feel daunted and left even more by the idea of choice?

My 'choice' was in reality driven by the lack of appropriate local services. If I could have used my local services I would have and this is ultimately what I see as the problem - a lack of local options which are able to provide appropriate high quality and flexibility in care.
d) Will this choice idea be backed up with a responsibility of providers to provide a range a service within their area so women do not have to travel out of area

My experience of mental health care was great at the hospital I was at, but I was then at the end of my pregnancy switched back to my local non-maternity services. It was not a specialist maternity service but general mental health services and they did not have a clue what to do with me or have any understanding of my needs.
e) Developing specialist maternity services is great, however there also needs to be a better overlap with general mental health services. Does this fail inside the remit of the changes or will there be no pressure to change related external services?

Choice is good. Choice is already possible under the current system for many women though. Its other gatekeeping issues that are causing many of the problems
f) How do you intend to remove the bias on information women receive as many of these 'facts' are institutionalised beliefs rather than evidence based medicine? Merely giving women money does not change the influence they face from HCPs
g) How much retraining will midwives and consultants get and will there be additional funding for this?
h) How do you intend to do this without removing the burden of responsibility from HCPS and instead placing it on the shoulders of women?

The idea of a budget gives the impression that women will be in complete control of their care. HCP are bound to 'do no harm', so how does this fit in with choice. Won't this still throw up some of the current gatekeeping issues that women already are facing in terms of their choices? Will HCP have the power to 'override' certain choices for 'safety reasons' if they feel if its not in the best interest of the patient. There are dangers in giving women the impression they can choose more than they can in reality.
I) How do you ensure a balance in the relationship between patient and professionals?
j) How do you ensure that women's perception and expectation of choice matches the reality?
k) How do you encourage flexibility and compromise rather than merely standardised ways of working within an add on system?

C-Sections are neither good nor bad in themselves. They are only bad if they are inappropriate. Comparing rates between hospitals can be misleading if other factors are not taken into consideration. Moves to reduce rates should not
l) Will there be an end to 'targets' within maternity care and instead simply encouraging the best and most appropriate care for each individual patient, using rates only in conjunction with patient satisfaction?
m) Will there be a ban on language with boasts things like being 'proud of out low caesarean rate' which attaches value, judgment and emotive associations to medical procedures rather than promoting the idea that all women will merely get the most appropriate care?
n) Will there be an overall of lumping together EMCS data and information with ELCS data and information?

It is not at all clear how different women will be accessed for a budget if they are not going to be classed as low, medium or high risk
o) Will women know their individual budget and if so is there a danger that women will lie to get a bigger budget due to perceptions that they are not getting enough / not valued as much?
p) On what criteria will women be assessed? Is the proposal something like a points system with women getting extra based on extra risk factors / social economic status?

[RevCharlotte]

When I travelled to the parent panel in Manchester, I shared my experiences of a preventable Group b Strep infection that nearly cost my son his life, and has left him permanently and profoundly disabled. I know I was one of a number of parents who shared their Group b Strep experiences with the panel, both in Manchester and in London - and in the case of at least two of these parents, their children died as a result of these infections. At the end of the discussion, Sir Cyril looked me in the eye and said, "I will do everything I can to make sure that what happened to you does not happen to anyone else." He also said that informing women of the risks of Group b Strep and testing for it just makes sense.

So please, can you tell me why there is absolutely no mention of Group b Strep in this review, or any recommendations for changing the current, inadequate, risk-based approach?

Baroness Julia says in her comments that she hopes this review will contribute to making NHS maternity care among the best in the world but the UK is seriously lagging behind in the issue of Group b Strep. A huge number of countries already test for this preventable infection and have seen their infection rates drop by over 85% as a result. If the NHS is going to even attempt to become among the best in the world, then we MUST change the current policy on Group b Strep.

The attached picture is my son, four years ago, fighting for his life against Group b Strep.

[April2013]

When I mentioned group b strep to my consultant recently, explained that I had privately had the test done, she was very scaithing of me having done this - why is this issue not in the report and why are consultants telling women it is a non issue?

[LovelyChubbly001]

Agree with other posters, why isn't ensuring pregnant women are informed about group B Strep in the report? It's a huge omission in current care. It was also discussed at the session I attended, where we were told the subject had come up many times (the implication was that it would be in the report). I'm very sad it hasn't.

[neef]

PMHull is absolutely correct to state that the reluctance to give women elective c sections and the the policy of a vaginal birth 'at all costs' over an emergency section is ruining women's and babies lives. I am a victim of the Morecambe Bay Trust vaginal birth policy and now have to live with permanent life changing vaginal and rectal injury and nerve damage after a botched forceps delivery. My son was, thankfully, left without physical injury but lost his mother for the first six months of his life due to the birth trauma and my psychological and physical distress continues to affect my ability to parent three years on. Is the government going to compensate women and children who have been affected by NHS failings? I fully support the recommendations made in the review, but what are the government going to do to support the women who have already been affected?

[RowanMumsnet]

Hello

Just wanted to clarify that we (MNHQ) were on the review board for the National Maternity Review, and did our best to feed in MNers' thoughts on various issues, gathered through this thread, a survey about partners staying overnight on postnatal wards, and lots of beavering about reading many many threads on the topic. Sorry to those who missed the chance to contribute.

[SouthwarkBelle1]

I welcome the idea of more choice and continuity but in practice will this apply to all mums? Will high risk mums or those who don't want a home birth be able to access caseload midwifery teams? In my area such teams exist and are great but are only an option if you are willing and able to have a home birth, private midwives also seem most interested in home/"normal" birth (and cost more than 3k). Will there be an enough MWs willing and able to provide caseload care for ALL who choose it? Will some choices only be available if you can afford to pay additional costs yourself?

[JugglingFromHereToThere]

I'm glad you were on it Rowan - I'm sure you did your best to share insights from Mumsnetters experiences and the discussions from the many excellent and well-informed threads we have had

[CazMoren]

Is this Q&A with the Baroness happening now?