16 week appointment as a group session!? Cost-cutting in the NHS

[Londonmamabychance]

Went to my 16-week appointment yesterday at University College London Hospital. This is my second pregnancy, and with the first (the care was also at UCLH) the 16 week appointment was a one-to-one with a midwife. Now it was a group session with 8 women in it. Each of us got our blood pressure measured behind a little makeshift screen, and before coming into the room was instructed to do a urine sample which was then tested behind the screen as well.

Afterwards the midwife sat down with all of us and told a lot of general information about the appointments we would be having, different options for birth and pain relief and a bit of advice on diet. And then asked any questions. Not surprisingly, none had any.

She also mentioned that they had decided to turn the appointment into a group session as "it was a waste of time for the pregnant women to have to come into the hospital just to have blood pressure measured and urine tested". However, she did not say how it was less of a waste of time to have to do this in a group, and afterwards sit through 15 minutes of general information, which I think all second time mums would already be aware of, and for first time mums, starting to talk about pain relief and birth options may even be a bit too early. The diet advice was random and scattergun, e.g. she mentioned not to eat runny egg yolk and raw fish, but did not mention unpasteurised cheese, never mind alcohol.

My main criticism of this practice is, however, not that it may be "a waste of time". I think few pregnant women find their midwife appointments a waste of time, given that most are quite anxious and love a bit of reassurance. There may be a few very confident mammas to be, who find the schedule of appointments a bit much, but I think they're far and few between, and making it into a group session did not this cut down the number of appointments anyway. The main problem as I see it is that most women do not feel comfortable talking about private issues in front of complete strangers. I and another woman hung back when the others left, to ask some private questions one on one, but it was not encouraged and the midwife, although not being unfriendly, did not at all seem to encourage it and kept us standing by the door while talking to us so we were made to feel as if she was in a hurry to get us out.

It's a blatant cost cutting exercise, and it makes me so angry that it is concealed with this nonsense of it being for our sake in order to "save us time". I am worried that it will reduce the quality of care, as many women may not feel encouraged to ask private questions or voice concerns, and the midwife does not ask each woman individually how she is doing.

It is the same with all the focus on women being "most comfortable in their home" while having the first contractions, you're positively kicked out of hospital if you come in too early. I'm sure many women may feel more comfortable at home, but you can't just make a blanket statement that all do. I, for one, did not, as I was very anxious in my first pregnancy and felt much safer being in hospital. When they insisted on kicking me back home when I first came in I said I wanted to stay, much to their annoyance, and I'm glad I did, because 4 hours after I was fully dilated and ready to give birth - and the hospital is 30-40 minutes away by car. And as everyone who've given birth knows, sitting in a taxi with contractions really isn't the "most comfortable place".

I am curious if other pregnant women have also had group sessions at their hospitals or local midwives/GP's, and if other second time pregnancies have noticed any worsening of the service and care they received compared to first time around, that is, if they're in the same birth centre/hospital?

[blue2014]

I'm first pregnancy and have just moved house. In the first area my first appointment was 5 mins and just involved booking my scan! When I moved the new service involved a home visit of an hour with all kinds of tests and advice etc. 16 weeks is 1-1 on Friday

So yes, it's a cost cutting exercise and depends on area

[seven201]

I think the concept is good but only if they add on a stay on at the end session if you have any personal questions. I don't know how much each pregnancy/birth cost the NHS but mine wouldn't have been cheap (high risk, complications, lots of extra monitoring, planned casaerean) so probably costs the NHS thousands. Group sessions financially make sense. I only went to two group sessions but they were specialist things - gestational diabetes workshop and what you need to know for a casaerean. I did find midwife appointments a bit boring/tedious (it was mostly her filling things in on the computer) so personally I wouldn't mind some of them being group sessions. Maybe they should offer people the choice...

[RaeSkywalker]

Yes, that sounds rubbish. Mind you, my 16 week appointment was about 10 minutes with the midwife, when I honestly eat like an inconvenience. She checked by BP and urine, listened to the heartbeat, chucked some leaflets at me, and then shoved me out of the door. I had to interrupt her to tell her I'd been admitted to hospital with HG and was now on medication, because I thought this should be put in my maternity notes. Without Mumsnet and Google, I would feel totally lost.

With group appointments, how on earth can they identify women who may be suffering from depression, or identify potential cases of abuse?

What infuriates me even more is that if I lived 30 miles down the road, I would have hour long appointments in my own home like blue describes.

[RaeSkywalker]

^ "felt", not "eat"

[MyBreadIsEggy]

My second pregnancy, and I was offered the chance to have a group session like you describe, or just to pop down to the children's centre at my own leisure, on the day the midwife is there for her clinic, pee in a pot, have my blood pressure done and be on my merry way.
I chose the latter. Can't think of much worse than a patronising group session

[pitterpatterrain]

My first pregnancy was at UCH. Second I am having elsewhere as it felt like a clinically focused conveyer belt there which I can 100% appreciate as they are so ridiculously swamped with demand vs what the unit was originally set up with.

Happier now I have moved even though it is to another London teaching hospital.

Curious whether there was a feedback route for you?

[Londonmamabychance]

Raeskywalker, interesting that they checked the heartbeat? When was this? Yesterday I asked if they could do it, as they did in my 16 week appointment with DD, but she said they no longer do it at 16 weeks as the machine may not be able to pick up the heartbeat and then you'd get anxious but it would still be "too early to say there was a problem and refer you to a scan". So basically, I felt that was another cost-cutting exercise - they don't want to risk not finding heartbeat with the machine and having to do an assurance scan. She said this was a new rule. Wondering if this is just at UCLH, or everywhere in the country?

[RaeSkywalker]

It was 3 weeks ago on Thursday. I think it depends on which area of the country you're in, I know that one of my friends who lives elsewhere wasn't offered it as 16 weeks.

[Londonmamabychance]

Thanks, Rae, it does upset me that the care is so dependent on where you live. I know there's a baby boom in London and has been for quite a while, and this is probably why they've become so tight with offering anything. I do think it's a bit weird though, that there will in practice be no check if baby is okay between 12 week scan and 20 week scan. But I guess we're also just so used to loads of checks these days, when our mothers were pregnant they hardly had anything, did they!

[RaeSkywalker]

It's not fair is it. There should be a national template I think.

I am massively pro-NHS, I think it's amazing. My antenatal care is the first time I have felt disappointed or let down by the NHS, and whilst this isn't making me anxious about the birth, it was making me very anxious about postnatal care. I'm actually going to buy formula and bottles because I'm expecting to get no breastfeeding support and have to give up- I know that this attitude is probably a self-fulfilling prophecy, but I think it's a sensible precaution to take based on my experiences so far.

The thing that makes me really angry is that I dragged myself to my booking appointment with the HG at its peak, vomited several times in the consulting room and collapsed on my way home. I was admitted to hospital the next day. On the other hand, if I lived in the next county, I could have forgone all of that and had my appointment at home. The appointment would have been an hour long, and maybe the midwife would've spotted how much I was struggling.

[SauvignonPlonker]

I'm wondering why people are so surprised about cost- cutting in the NHS? Services are being cut across the board, maternity services included. There's huge pressure to deliver the same outcomes for less resources.

The midwives could probably see 8 people in an hour as part of a group, versus 8 people in a clinic lasting 3 hours.

I think we'll see a lot more of this in the NHS, rightly or wrongly.

[RaeSkywalker]

Sauvignon I'm not surprised to discover cost-cutting. I am surprised in how the quality of care ranges so drastically across the country. I am surprised at how these group sessions can possibly have been deemed appropriate for identifying potential issues with patients. I am surprised about the lack of information about the differences in care between different areas.

And, as with many other areas of the NHS, I am surprised by the short-term thinking that seems to have driven these changes. Yes, you've saved time and money by cramming a load of women in together. But if a couple of those women have the early signs of antenatal depression, how would they be identified? The NHS is setting itself up for a greater burden of cost further down the line. But of course the people who instigate these changes aren't made to consider it, because they're just focused on getting their own costs down, rather than considering the implications for the organisation as a whole.

[Londonmamabychance]

Rae, that sounds so tough! sorry you had to go through this. -Don't give up on breastfeeding before trying! I think there's a massive worry about it in this country because many women don't manage to do it for long so it's made into this big thing - but it really doesn't have to be. For many women it's very easy and natural! Not that that should make you feel bad if you're struggling a bit in the beginning, that's natural too, but I think there's too much focus on how hard it can be. Just put baby there as soon as he/she is out and keep doing it and you'll get the hang of it. Women have been doing it all over the world all though history, and before there was bottle milk, everyone did it! I know it's easy for me to say because I was very lucky and had an easy time of it, DD latched on very well and I had tons of milk (in fact so much over- supply that I got mastitis and that was bloody painful, but never mind, it didn't last long and it was worth it for the wonderful convenience and bonding it was to BF, did it up to 15 months). Anyway, stay positive and tell yourself you can do it!

Sauvignon, you're right, probably shouldn't be surprised, we will see it more everywhere, sadly. I guess I'm just surprised to see the massive changes in the same hospital only 20 months after giving birth there and having been very happy with the care!

Pitterpatter, is it too personal to ask where you've gone instead of UCH?

[RaeSkywalker]

Basically, on an intellectual level, I am fully aware of how and why this is happening. But actually experiencing it is totally different.

[RaeSkywalker]

Thanks London. I won't give up, just think I need to prepare for the worst case scenario because I don't think that the support will be there if I do struggle. It's nice to hear that you found it ok, most stories I read make it sound awful! It does annoy me that there is so much emphasis on how breastfeeding is the best option for the baby in NHS antenatal care, but postnatally there is no investment to support this. I have several close friends who were desperate to breastfeed having studied all the NHS literature, struggled and asked for help, and got none. They now feel guilty for 'failing'

[Lj8893]

As a student midwife I am really surprised at this! If the hospital I worked at during my training started doing this, it may well make me question midwifery as a career choice. I've gone into this career as I want to spend time with women and it's a women centred role, and what you have described is the complete opposite!

Talking about listening to the fetal heart, NICE guidelines actually state there is no need to listen to the heartbeat at routine antenatal apts as fetal movements and growth are good enough indication of wellbeing. And yes it can cause unnessary anxiety if a fetal heart is not picked up at 16 weeks which is still pretty early. However, most midwives do listen to the fetal heart at every apt as it's nice for the woman and good for bonding.

[Londonmamabychance]

LJ8893, thanks for your advice on the NICE guidelines on listening for heartbeat - but at 16 weeks you don't feel any movements, and it's been 4 weeks since your last scan and still 4 to go to the next, so how would you have indication of wellbeing without listening for heartbeat? I'm just asking out of curiosity, I do completely accept that it's a bit of a risky business to try to find the heartbeat risking that you won't and then causing upset for the pregnant woman for no reason, as it can often be just because of the position of the fetus.

I think maybe hospitals and birth centres in London are particularly stretched. Curious if any other London mums to be find there hopsitals better?

Rae, I know lots of women struggle with breastfeeding but don't forget lots find it quite easy too! It's all about keep trying and don't stress too much about it. You and baby will work it out together. I actually found that all the literature made me more nervous, and breastfeeding NCT class just made it seem like this big, mystical thing that it really isn't. In the end, what really helped me was just putting baby there, in my way, and getting on with it, and not worry if the position was perfect, if it was frequent/too frequent etc. Trust your instincts and your baby and you will be fine!

[Lj8893]

I completely agree with you regarding those points, I think listening to the fetal heart is an important part of a routine apt. Not just for fetal wellbeing but for maternal wellbeing also.

Rae London is right about breastfeeding, the literature is great to have yourself armed with preparation and the how to's, but being relaxed and letting yours and yours babies intuition do the work is so important!

[expatinscotland]

Maternity is the bastard stepchild of the NHS. It's a wonder they don't have women giving birth in group tents.

[Londonmamabychance]

LOL, Expats, don't give them any ideas!

[HopelesslydevotedtoGu]

RaeSkywalker would you consider a couple of sessions with a private lactation consultant if you are having difficulties and your local bf services are poor? A few friends did this (they found them via their local nct/ mum's Facebook group) and breasted successfully. Whilst they had to pay for this, they didn't have to switch to formula and pay for that. In my area the nhs team luckily does home visits for newborn- no way would I have wanted to travel to a children's centre session in the first week.

Breastfeeding support differs in different areas sadly- I went to two different breastfeeding cafes and one had a great advisor who gave really specific advice, another a well meaning but sadly clueless hv who knew less about bfing than many of the mums.

[GraysAnalogy]

This is ridiculous.

I also despise group CBT sessions too, another cost cutting exercise.

Underfunded, understaffed :(

[Cherylene]

I remember people complaining about group appointments in the 1970s and being told to take their knickers off in the corridor so as not to keep the doctor waiting

I thought they were abolished because of the lack of dignity and privacy.

[riddles26]

I am at UCH and was disappointed by the 16 week appointment too. When I had my booking appointment, the midwife did mention that there would be a group component to the 16 week check up where they would show us the birthing suite but both my husband and I interpreted this as an individual midwife check up followed by a group session on birth. We were both surprised with the actual outcome and didn't find it particularly useful.

I am also disappointed with the the information (or more lack of) that has been given to me by UCH. I was reading the maternity notes book from St Thomas and they give such detailed information on diet in pregnancy, travel advice, managing basic activities as bump grows etc. In comparison there is nothing in my book and none of the above have been discussed at any appointment either. They have also recently removed the 32 week growth scan for low risk pregnancies - more cost cutting - I picked UCH as my hospital largely because they offered that additional scan that few others do. If I am fortunate to fall pregnant again, I will probably select Kings or St Thomas despite the longer travel time.

On the other side, their early pregnancy unit is absolutely fantastic - I have read countless other posts on here from women who have had bleeding and their local unit have not been able to review and scan for 3-5 days. In comparison, I had bleeding at 13 weeks and they scanned me that morning. They were also wonderful and supportive when I had a miscarriage last year.

As a healthcare professional who works in NHS, I experience the other side of the cost cutting every single day so I do see where they are coming from but I do feel a little unsupported over the first 2 trimesters; I am just lucky that I know a lot of the information they have failed to provide and have access to speak to midwives I personally know through my profession.

[Londonmamabychance]

Riddles, good to hear your experiences. Can't believe they've cut the 32 week scan! I was so happy to have it last time. I wonder if they offer it at St Thomas.