AIBU to think that the £3000 budget for births is potentially a misleading con.

[RedToothBrush]

Women to be offered their own £3,000 'birth budgets' announced today.

Sounds great in principal. But it worries me too.

The way it sounds is that the idea is to let low risk women choose the care they receive. My worry with it though is it will mean that women are pushed into the low risk category even if not appropriate. I think it could have real implications for VBAC v ELCS. I note that no where does it say anything about choosing an ELCS. Would there be concerns where someone has 'used up' their budget and then couldn't afford pain relief? (Incidentally the cost of an ELCS was estimated as £2,369 by NICE in 2011 guidance). What if the hospital closest to you and your preferred choice is too expensive so you have to go to the unattached birthing centre otherwise you won't get breastfeeding support?

Also when its being described in the article, I get the impression that one to one care, home births and extra breastfeeding support are being framed as extras or expensive options rather than basic bog standard choices. Given that a homebirth is the CHEAPEST option, I find this misleading. Given each of these has proven long term health benefits which make them cost effective and indeed economically preferable it makes me raise my eyebrows.

The NHS patient charter states that all patients should get the most appropriate care for them already. This just appears to be a media headline grabbing stunt, which in practice could in fact be a way of LIMITING options rather than expanding the idea of raising the baseline for ALL care.

It strikes me as really smoke and mirrors to look good and win support. Its being heralded as empowering women. I personally think that empowering women with regard to childbirth isn't about budgets but attitudes within society and within medical circles. (Again going back to the article the fact that ELCS are not mentioned highlights the point to me)

(Incidently as an aside, the NICE guidelines for CS are due for review this year. I know there are a lot of women on MN who are pro-choice for ELCS for various reasons. I have grown alarmed in the last 6 months that there seems to be an increase in rationing ELCS going by the posts on MN. MN could in theory register as a stakeholder to represent some of our views. I would be over the moon if they could as there are very few organisations that directly represent the experiences of women in this area).

[StarlingMurmuration]

YANBU. I think it's potentially very worrying - how long before this nominal budget becomes an actual limit? I had a lot of pregnancy related illnesses, a difficult and probably expensive birth, and birth related injuries which required surgery six months later. I also had PND and so have had a lot of mental health support. I must have cost the NHS way more than £3000.

[SeldomAthleticFC]

I was wondering what happens if someone opts to spend £3k on a homebirth with a pool and hypnotherapy but, for whatever reason, ends up in hospital. Will they say - sorry, you've spent your £3k, you can't come in!?

[NoArmaniNoPunani]

YANBU. I was a low risk planned home birth until I developed HELLP at 36 weeks and became extremely high risk and needed an emergency C section. I doubt if 3k touched the cost of care for me and DS to get us both well again.

[Anniegetyourgun]

I was wondering how they'll manage to cover all the options. You can't just switch maternity provision on and off. £3k may be the cost of a certain type of birth but you can't magic up extra trained clinicians with a maximum of 9 months' notice because x number of local women have decided they want, or turn out to need, y type births this season. There would have to be redundant provision to cover emergencies at least - different how to current system? I'm inclined to agree, smoke and mirrors, with the ultimate objective of squeezing budgets.

[IAmAPaleontologist]

The oddest thing is that we are perfectly entitled to choose our care anyway!

[BillSykesDog]

YABU. This isn't going to limit care, it's extras rather that a limit saying 'this is all you can have'. It's not going to mean if you make a plan for your 'budget' if your needs change you won't be given what you need. It's not going to mean emergency care isn't available because your budget has been spent. The pathways for emergency care will remain the same and won't be based on cost.

NHS breastfeeding support will remain the same. This refers to extra breastfeeding support, so for example a non-NHS breastfeeding consultant to support you at home.

In all honesty, this is an absolutely hysterical reaction OP. Do you really think the Royal College of Midwives (who are a lot more informed about it) would be welcoming withdrawing anaesthesia and breastfeeding support?

[Cosmiccreepers203]

Agreed. This looks to me like another step in potentially fully privatising NHS Services. Once we have this budget then what is to stop them asking us to top it up for 'extra' services that we already get for free. What we really need to do is ask the government to invest more money if they want a world class service. For example, what about the review underway to decide if women should be routinely offered a scan at 36 weeks to help cut the rate of stillbirth? Are we going to end up paying for these scans?

[megletthesecond]

Yanbu. I also suspect it's something to do with long term planned privatisation.

[IAmAPaleontologist]

Also, while I do welcome that women will be able to elect to spend the money on a one to one service, I would be very surprised if this stretched to all independent midwives rather than the one to one services that already operate and take referrals for the nhs. If women don't have a facility available in their area the they can't choose it budget or no budget. My area has no midwife led unit. If it did have one then I could choose to have my care there anyway. While we have a fair few independent midwives we do not have one to one or neighbourhood midwife type care available.

Bf support should be available as necessary anyway given that the lack of bf if one of the biggest public health concerns around.

Why are they saying that we could even choose to spend it on having a home birth? I can have a home birth anyway thanks. With the nhs. As it is. So can anyone else.

Having hypno and so on is interesting though I'd be interested in knowing how they would regulate who you got classes etc from. There is a lot of pregnancy type alternative stuff around at the moment. Lots is excellent, has a strong evidence base an good practitioners. Some is a pile of crap and is just a franchise run by someone who had half a day training.

[AlbusPercival]

Thank God OP, I thought I was going mad this morning listening to this on the Today Programme. Surely everything should be an option?

I can totally see this becoming, "you can have a homebirth, or breast feeding support, but not both"

[RedToothBrush]

This is my point though Billskyes. One to one care SHOULD NOT be an 'extra'. Indeed, its supposed to be have been part of the vision for improving care across the board as being available to all as standard care. Nor should a homebirth be regarded as an 'extra'. You are entitled to one as part of your human rights under EU law. (Which perhaps is something we should be concerned about in the context of the looming referendum). Basic breastfeeding support is consistently criticised as not being fit for purpose and begs the question will even basic support then be classified as an 'extra'.

I do think the RCM have a vested interest here and a certain agenda about reducing ELCS as well. They are not an impartial body and have repeatedly come out with things in the past which I don't necessarily fit with women's choice, but do fit with their own vision. I have found them somewhat shortsighted and naïve at times in the past.

[Cosmiccreepers203]

Also, reading article, it appears that this £3000 is what it already costs, not more money on top. So what happens if your care costs more? It really isn't clear. Women need to have the clear plan completely revealed and explained, including impact assessments for all areas, BEFORE they start rolling out trials in some areas of the country.

I find it a bit offensive that good breastfeeding support, home birth and ELCS (all freely available now) are being dangled as bonus 'optional extras'. He thinks we're stupid.

I really don't feel like the man who wrote a book about how to privatise the NHS for profit can be trusted to have patient interest as his primary concern.

[Potatoface2]

i think that CS should not be given as an option/choice unless there is an underlying reason ...ie previous emergency CS, pre eclampsia etc.....a medical doctor should be the one opting for this in a best approach for mother and baby...it is an invasive procedure which can cause complications..not as an option by a mum to be who doesnt want a natural birth for whatever reason SHE decides.....it should be a medical decision.....also i think if some one opts for a home birth and use all their 'budget' and need to be admitted for whatever reason and needs an CS then it is deemed an emergency and that will not come into the budget as all emergency treatment is available to anyone 'free at source' (this includes non british people needing any treatment)

[KitKat1985]

I think it's madness. Some births will be straight-forward and require little intervention, in which case £3000 would be far too much money allocated; and others, invariably, will be far more complex and £3000 won't be anywhere near enough. Why can't they just treat each woman in labour individually rather than set an identical 'budget' for everyone. It's one of those cases where it's not appropriate to give everyone the same 'budget' because everyone's needs will be different.

I can see this madness spreading to other NHS departments. Imagine being told in A&E you have a £3000 'budget' for your emergency care.
"Oh yes madam you can have the surgery for the broken leg, but I'm afraid you haven't got any budget left-over for any pain relief".
Or conversely "well those stitches only cost £200, you can still have another £2800 worth of free medical care if you like?". "Oh excellent, I'll have the free MRI and a cooked breakfast".

[BoomBoomsCousin]

I think the recommendation is supposed to pressure NHS providers to actually provide the one on one care they are supposed to be working towards. At the moment with centralised services it is easy for managers to take away that option from women in order to shore up services elsewhere.

Whether it would be effective is another matter. I would be concerned that it would push risk for services failing from the hospitals on to patients, and that over time costs would go up, but the individual budgets wouldn't, so women's choices would slowly be curtailed. But I don't think that is necessarily how such a scheme would work and I don't think current practices are providing low risk women with the options the NHS is supposed to be trying to offer them.

[RomComPhooey]

I had a post partum haemorrhage with DS2 & the clotting drugs alone were £1,500 (anaesthetist told me) - and I still ended up in theatre under GA to sort it out & that's without the cost of my EMCS or DS's spell in the nicu. I don't think this is driven by choice at all & it actually restricts women's access. In no other medical area would a non-expert patient be expected to work out what is the most appropriate care for them or to evaluate the risks of different treatment options. We don't need a showy scheme like this. We need high quality safe maternity care, irrespective of where you deliver.

[RedToothBrush]

Potatoface under current medical guidance drawn up by NICE women are allowed to have an ELCS as long as it is discussed with a medical professional because it is deemed safe in comparison with a VB. It was viewed potentially MORE harmful to prevent a woman who wants to have an ELCS from having one. This was after a consultation on the subject.

Then there is the issue of VBAC v ELCS. The advice is that a woman's view should be strongly regarded and should be part of the process, yet there are a lot of women who are being pushed down either route against their wishes because of hospital policy and preferences.

And finally the psychological aspect of having an ELCS is widely disregarded by many Trusts as not being a 'valid' reason even though mental health is a health issue. A huge percentage of women requesting an ELCS do so on the basis of mental health but the system still classifies them as 'maternal request' which is not helping women and is hugely misleading. Whenever I read threads on the subject, more often than not, women say 'with no medical reason' because the message has not got out to women and health professionals that mental health is a medical reason.

The issue of the complete lack of maternity mental health services in some areas is scandalous.

This isn't a thread about the merits of VB versus ELCS really so I don't want to get into that. It is one about choice producing better outcomes for women and how women get their voices heard and respected to get that choice.

I think your post does a lot to highlight the preconceptions and prejudices out there and the lack of evidence based medicine that is being used to help outcomes and shows up just how 'politicised' choice has become. Using money in this way, only has the potential to be exploited by those holding the cash rather than the women spending the cash in just the same way as it currently is. Its only changing attitudes that improves things.

The underlying message that comes out in research is generally that listening to women properly improves care and outcomes across the board. I fail to see how this really addresses the issue. There is no more funding and all these services already exist. The question is why women don't access them currently and why they don't make those choices already? That's not about them not holding the cash, its about gatekeeping and knowing what services are available. And those services even being available in the first place.

[babybat]

YANBU - offering women choices in their treatment should be something we're doing because it's the right way to treat people, not because we're consumers. The option to choose where and how to give birth should be something that women are able to discuss with their midwives and reach a decision that's right for them. In theory this should already be open to everyone, but I think often some HCPs/hospitals work on the basis of 'this is our policy', or 'we strongly advise you do this' and not every woman will feel comfortable challenging that attitude. The way to change that isn't to give women a budget to spend, but to work with patients and doctors to encourage a more collaborative approach.

So far during my pregnancy I've had dedicated support from a named midwife and student midwife, I've chosen the MLU for the birth, and I've been encouraged to make decisions about important aspects of my care. I've been able to do that because the people looking after me believe it's important, not because of any sense that I'm a customer. Ascribing a monetary value to the health service won't improve care, it'll just be another step towards getting us to think of the cost of everything, rather than the value.

[Samcro]

yanbu i was low risk both times. both times I became high risk and god knows how much the second one cost

[RedToothBrush]

offering women choices in their treatment should be something we're doing because it's the right way to treat people, not because we're consumers.

I think that sums it up perfectly for me. I find the undertones of the whole idea suggest women being demanding or having expectation beyond a basic level of appropriate care for their individual circumstances. I think this is actually undermining the whole message about 'better care for all' or women centred care. I'm not sure how that empowers women. Quite the opposite.

And as someone else upthread has mentioned does start to put it in the framework for privatisation with certain things viewed as 'add ons' and 'extras'.

[BestZebbie]

At what point do you 'spend' your budget, also?
I can totally imagine writing a beautiful budget for a pool, aromatherapy etc and then a few hours in being happy to pay £3000 and give them your car too if they'd just bring some drugs...

[BoomBoomsCousin]

I disagree that who is holding the cash won't impact the choices available. If implemented well, women holding the funds could cut through a lot of red tape and centralised planning that does not listen to women's voices. Even if implemented poorly it will mean service providers could court women with the sorts of services they want.

[timeKeepingOnMars]

The way it was phrased on radio this morning was one to one midwife care or HB.

I've had one to one MW care and MW led unit birth.
One to one MW care and HB.
Random set of MW and HB.

In unlikely event I had another the best for any low risk pg I would want one to one mW care and HB - would I be able to afford both and if not would I be able to top up with own money to get more options?

HB are cheaper - but with third pg I lived in an area anti HB would they be able to get rid of that option by making it more expensive and out of most women's reach?

What if I insist I'll only pay for cheaper HB option and I know I'll need expensive support post birth but it''s not medical a good idea? Would there be option for hospital to top up or override?

What if I have a HB - and budget for that then get transferred into hospital not unheard of - at what rate would this be taken out of my budget?

How do you budget when birth and post birth can be so unpredictable?

This seems to be the illusion of more choice but I suspect it's so we get used to equating care with money so get used to paying for NHS services - then in future state can reduce the amount allocated and expect initially wealthier to contribute then everyone possible with very poor getting bog standard safety net service.

[Voldetort]

I can see it creating a two tier system. Those who can only afford the 'basic' pregnancy and birth within the £3000 - one scan at 20wks, no extras, standard VB or ELCS (decision made by doctor, not mother) one night in postnatal with food brought in from home and then out. And those who can afford the 'better' package - half a dozen scans at various stages, whichever type of birth they choose, one to one care, own room on postnatal with BF support, etc.

[Cosmiccreepers203]

BoomBoom but isn't 'courting' women with services just a way of consumerising the whole process? I agree that women need more choice, especially in trusts that are underfunded. But the answer to this is not to turn women into consumers. I'm not a consumer. I'm a patient. I expect the best and most appropriate care possible to give me the best outcomes. There are some things it is right for me to have a choice on and others where my doctors are the best qualified to decide. But it should be a process between doctor (or midwife) and patient. As soon as you turn people into consumers of services you change that relationship. I don't want to be sold services I might not need or want because some trust manager has been incentivised to sell them.

There needs to be more investment in NHS services to provide patients with what they need. This proposal doesn't appear to offer any more money for these services to be introduced to every trust. Where does the money come from for offering extra breast feeding sessions, hypnobirthing etc? I agree these things should be widely available already. The government is ducking out of it's responsibility to us by trying to make us into consumers and therefore shunting the decision, and therefore the eventual blame, about the state of services in our area onto us.