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).

It's totally nonsensical, IMHO. It's based on this illusion of consumer choice in healthcare, which to me looks like an exercise in training us to see ourselves as healthcare "shoppers", picking and choosing from a range of services. Probably to get us used to the idea of privatised, broken up healthcare that the Tories see as the future of the NHS.

Problem is, healthcare (and especially childbirth) isn't like buying electrical goods. We don't have total agency over what our bodies decide to do, and there isn't an infinite range of services to pick and choose from out there anyway.

Is the idea that a pregnant woman sits down with her MW before the birth and goes "OK, I'd like to give birth in the pool in the birthing unit, and that will give me enough over for 5 one to one post natal MW visits and some breastfeeding support? How is she going to KNOW what she needs in advance??

FFS, you can plan a ELCS on your due date and give birth on your bathroom floor a week in advance, with no cost to the NHS except a quick whiz into hospital to check you both over. You can be a low risk multigravida who's had 2 easy births already, plan a nice easy birth in the pool in the birthing unit, and end up bluelighted into hospital with all sorts of complications for a crash CS, and your baby could spend 2 weeks in NICU, and you could need weeks of breastfeeding support and counselling for PSTD, costing the NHS a 6 figure sum.

Trying to monetise individual healthcare in this way, especially when we're talking about birth, is utterly asinine IMO, and truly illustrates the saying about knowing the cost of everything and the value of nothing.

I think it's fine. In our area women can self-refer to One to One Midwives to provide some or all of their care. They are registered with the CCG and just get the elements of funding that would be given to the hospital trust if their midwives had provided the care.

If the woman chooses to have 121 for antenatal and postnatal care but delivers in hospital then 121 get the funds for the antenatal and postnatal 'episodes' of care and the hospital get the part for the birth. If the woman choses a home birth with her 121 midwives all the way through then they claim all the funding.

The system already works this way in parts through CCGs. It's just that the commissioning groups get to pick and choose whether to fund those services (so women in a neighbouring area can't choose to self-refer to 121 because their commissioners won't fund them)

redtoothbrush....every mum to be is different...some are clued up to procedures/options etc.....they go to all ante natal appts and read up and become well informed, discussing options with doctors and midwives.....some dont...they think they will be okay, dont become informed, dont look at choices and certainly dont care about funding issues. I understand about all sorts of issues as to why women NEED CS.....but WANTING and NEEDING one are different....that is why it should be discussed with a doctor, which helps make an informed choice......giving birth vaginally is scary, but giving birth via CS is far scarier (ive had both).....informed choices and discussed options .....but cant see how they can stick to a budget for each birth....they dont for any other operation in the NHS as we are all individuals who react different to every single thing!

YANBU. I don't like the idea of this, one bit. If all that cash were spent on improving services and MORE MIDWIVES it'd go a long way to improving things. Sounds like a cop out, to me. And in practical terms, impossible to do.

Oh, forgot to say...Typical Fucking Tories. NO IDEA of what ordinary people want from a health service.

Pricing up and separately accounting for each individual service, per each individual service-user, is an essential piece of bureaucracy for pay-per-use healthcare.

At the moment I doubt any maternity unit does that (even though they know overall costs).

So regardless of where the money for "personal budgets" currently comes from, this is a way of forcing maternity units to start producing a price list and individual billing. Because this is what the privatisers need.

So NHS England have commissioned a independent report, this is what it asked for:

www.theguardian.com/society/2016/feb/23/national-maternity-review-calls-for-personal-care-budgets

So they've done what the report asked, and apparently they're bastards. But if they hadn' done what was asked they'd still be bastards. Righty ho then.

Incidentally, nowhere did I say this was to pay for 1 to 1 care. People will still get that - it will pay for addtional 1 to 1 care eg a doula, breastfeeding consultant etc. Choosing them won't mean that you don't have access to the normal NHS midwifery or breastfeeding support services.

I do have to say that there are parts to the report I AM liking a lot and its a real shame that this is actually the bit grabbing the headlines.

I'm still in the process of reading it (Its 120 odd pages long)

In terms of safety it is good to recognition of tears and mental as an issue, noting the wide disparities and lack of provision. The following paragraphs jumped out at me:
in first-time mothers the proportion of instrumental deliveries resulting in third and fourth degree perineal tears varied from 3% in the lowest decile and 11% in the highest. In women having a second or subsequent child, the variation between lowest and highest deciles was from 0.4% to 4.6%;

Late maternal mortality in the period 2011-13 was 14 per 100,000 maternities. Notably, 23% of these deaths were from mental health related causes, with one in seven dying through suicide.

Mental health problems are relatively common at a time of significant change in life. Depression and anxiety affect 15-20% of women in the first year after childbirth, but about half of all cases of perinatal depression and anxiety go undetected. Almost one in five women said that they had not been asked about their emotional and mental health state at the time of booking, or about past mental health problems and family history. Many of those with mental health problems that are detected do not receive evidence-based treatment. There is a large geographical variation in service provision: an estimated 40% of women in England lack access to specialist perinatal mental health services. Given the contribution of mental health causes to late maternal mortality, this is a significant concern, as also set out in NHS England’s recently published Mental Health Taskforce report

the 2011/12 RCOG Clinical Indicators project found marked differences in the proportion of women having an emergency caesarean section following spontaneous onset of labour, taking onto account clinical risk factors and socio-demographic differences; there was a 2.5 fold variation in first-time mothers, from 7% in the lowest tenth of Trusts to 17% in the highest tenth; amongst women not in their first pregnancy, the variation was 4.2 fold, with proportions varying between 1.2% and 5% from lowest to highest tenths

the 2015 MBRRACE-UK confidential enquiry into stillbirths found that two thirds of women with a risk factor for developing diabetes in pregnancy were not offered testing which could have identified the need for treatment; the same enquiry found that national guidance for screening and monitoring the growth of the baby had not been followed in two thirds of women whose babies were stillborn

However it also pointed this out:
We were told that women do not always feel like the choice is theirs and that too often they felt pressurised by their midwives and obstetricians to make choices that fitted their services. They resented the implications for their care of being labelled high, medium or low risk. Above all, women wanted to be listened to: about what they want for themselves and their baby, and to be taken seriously when they raise concerns.

So if women are to be given a budget based on whether they are low or high risks (which I'm convinced it will be when implemented), this is massively at odds with the report. So far everything is suggesting that this is going to be the case though - how can you do different budgets women can control if they are not classified as low, medium or high risk?!

I also see that this payment system is to replace the current tariff system which is good as it wasn't serving anyone. The problem is I'm not sure this will address a lot of the existing problems either.

I hate this idea and can see it as others have said to a way to in the long term restriction of care based on the lowest needs of care rather than appropriate care.
I'm sure the original idea is made with the best intentions but the current politics of healthcare are likely to distort this. We shouldn't be treating people as customers, but looking at improving services and consistancy across the board and making sure people don't slip through the cracks.
I feel this is headline grabbing rather than tackling the real issues with MW & obstetric staffing.

I had my first in Canada, where costs for things are much more transparent. I know that the first trimester care was about $1500, the second about $2000 and the third (not including birth) was $3000 - because I was potentially going to have to pay some of it (I had to pay for the second trimester only in the end - I wasn't there for most of the 1st and they were very reasonable about it)

I think it's bizarre to have a budget for something that's so different for everyone.

I think the Canadian system, which is a single payer system I believe - all the midwives and blood test clinics etc. are independent, and they charge the government for the work done, or you if the government doesn't cover it - works better than this weird half-arsed version.

I'm more interested to see what's suggested and happens with funding more complex care.

Just from what I've read on it a large part of the reason maternity units seem to struggle is that care for women with complex medical conditions aren't funded in the same way they would be if they were getting acute care from another hospital. So they'll get a higher payment than the £3000 for their complex pregnancy care, but from what I understand this ideally should be even higher to account for both the element of care that's their more complicated maternity provision and also an additional sum based on what they'd get if they were in an 'normal' hospital being cared for based on their condition and not their pregnancy.

I don't like this at all just another step towards privatisation.

anastasia, it's not a recommendation to say that the system already works this way with the CCGs.

Because the CCGs only came into being in the last 2 or 3 years. They were invented for the same reason, to fit the fragmented, privatised model.

There is no evidence yet that the CCG model is a good thing. They haven't been running long enough.

And there are substantial concerns about the fragmentation: continuity of care, information transfer, organisations squabbling about who gets paid for what, and the bureaucratic costs of hugely increasing the number of different organisations required to work together on a single person's care.

Fragmentation was at the heart of some of the recent major rail crashes. It's known to introduce dangers.

I'm going to make the assumption that no one is actually going to deny medical care to someone who's 'used up' there £3000 allowance when it actually comes to the birth and any complications.

What I wonder about is how much 'choice' people will actually get. When I had ds last year, I felt that I had complete choice over where I gave birth. I went with a big city hospital which is a leader in obstetric research for my antenatal care over the local hospital which doesn't have a great reputation or facilities, but planned to give birth in another stand alone midwife unit which was also out of area. In the end I had to be induced ending up in a emcs and I'm glad that I had chosen where that was happening.

However I could make those choices because I have the means to travel easily, am a professional in the public sector so am completely happy at knowing what my choices are, didn't have any other children to worry about, supportive dh etc etc. If I was someone who had no money to travel, didn't speak great english, didn't know or have the ability to research my options, was intimidated by hospitals and professionals, no or unsupportive dp etc. like an awful lot of women who live locally to me then in reality I wouldn't have had the choices I did, even if technically they were there to make.

In my area for most women the only option is the local hospital which is massively overstretched and understaffed, and currently in special measures. There is a birth centre there but it's often closed due to lack of staff and in reality isn't massively different to the labour ward. The nearest stand alone unit is out of area (although it's brilliant for the women who can use it). Home birth is fairly well supported locally, but it's a choice lots of women aren't comfortable with. I don't see how the £3000 allowance is actually going to change the choice available.

It's like school choices - yes parents have the ability to choose in theory, but in reality it's only actually available for a limited number and is largely dependent on your economic and social status.

Any mention of a budget per woman is quite concerning isn't it? Free health care at the point of need and all that - the guiding and founding principle of the NHS.

Reminds me of when I was fortunate enough to have a water-birth at St. George's hospital in London in '99. All good but they did ask me (afterwards) if I'd like to voluntarily give something to cover the additional cost of using a pool. I said I'd rather not as I felt that it was a perfectly reasonable and normal birth option that was no more expensive, and possibly cheaper, than other birth pathways/ choices/ interventions. And DH is a bit of a tight arse LOL and I was busy cuddling DD. Partly a matter of principle too I felt

When I had DS in another hospital a few years later they claimed that the water-pool room was unavailable due to being re-decorated. Hmmmph!
Again you slightly wonder if that was easier and cheaper for them?

I think that on the surface it sounds great for women who have the time, education and understanding to make research informed decisions about their care, and live in areas where there are a full range of options available. I can see that it will stop medical professionals doing things 'just because '. However I fear that there are a huge swathe of families to whom this will not benefit. Those who can't access the information (time, poor reading ability, English not first language etc ), or those who know what they would like to access but can't because it doesn't exist in their area.

A better solution would seem to be focus on addressing the inequality before putting this budgettin

It's like school choices - yes parents have the ability to choose in theory, but in reality it's only actually available for a limited number and is largely dependent on your economic and social status.

Agree completely.

Supposed choice in schools hasn't got rid of bad schools. It just means the sharp-elbowed squabble ferociously over what they see as the good ones, people end up trying to get three children to three different schools every morning, and education budgets get spent on advertising and on policing people renting a flat in the catchment.

Meanwhile, shit school is shit, and the losers in the squabbles still have to go there.

In our area women can self-refer to One to One Midwives to provide some or all of their care.

When I had one to one MW care who had to be in a particular district - registered with a set of GP. If when we moved we'd found the closer GP down the steep hill off our routes to work first I would have been ineligible for it. You had one to one and no other option was offered unless you switched to consultation led with a more complex pg. There were no options offered.

Where I had my third pg there was no one to one MW care at all available nor where my Dsis had her pg.

I agree it's like the illusion of school choice.

Last pg I could have the local hospital where the staff were very paternalistic and one mother I knew lost her child because they refused to listen to her with ongoing legal action- and many other mothers I knew has stories of not being listened too. Or My GP said I could go to the nearby city hospital - 30 min drive when we had no car and no childcare for younger DC which was so badly staffed and struggling is was getting at the time national presses on how bad it was. My choice sucked basicly and being new to area had no idea till already pg. It was why we fought so hard to have HB.

Reading through the report it does say that budget relating to mental health support will be in a different pot of funding which is good. Whether this covers women choosing an ELCS over a VBAC or other 'maternal requests' on the basis of mental health remains to be seen and relies on the provision of services and diagnosis of mental health issues, which naturally is going to be easier in places where there actually IS a service... It has made me feel a little better but it still raises a lot of questions to me.

I completely agree that the pointy elbowed will get better care with budgeted services in this way. I got excellent care and choice, but I do think that I had the ability to get this that an awful lot of women who had similar issues don't. And that was still down to the lottery of where I lived too.

I don't think it will address so many inequalities in care on a national level. In fact I fear the opposite.

Will people know their budget? Will they compare? And if they do and find their mate has a bigger one, will that influence what they tell their HCPs in order to get a bigger budget?

Getting on this thread to read later

I think that CS should not be given as an option/choice unless there is an underlying reason

I couldn't disagree less. Women should always have autonomy over their own bodies. And vaginal births can lead to lots of complications, far more than an elective CS in fact.

What's right for you isn't necessarily right for other women.

I think this is absolute bullshit, as most "choice" situations like this are.

Just picking up on something from your opening post RedToothBrush where you say you think the idea is to let women with low risk pregnancies choose the care they will receive .... well up to a point that's good, but I really like the principle that all women can choose the care they receive and make decisions based on their choices and often changing circumstances (of labour)

My birth plans worked through all possibilities in as far as I understood them and this was an important part of preparing for birth for me. I didn't want to feel that the birth plan would need to be "thrown out of the window" at any point. Yes I might have needed an emergency CS if that was what was best, but I could still consent to this, and be a part of the decision making process.

I don't like the implication that only women with low risk pregnancies have choices to make. For example one of the most important choices for me was having immediate skin to skin contact straight after the birth, something that should be possible much more often I would think?

I should read the link too though!

well said Boredofusername !

And if they do and find their mate has a bigger one, will that influence what they tell their HCPs in order to get a bigger budget?

As we know from disability benefit threads, nothing brings out the raving loon in some people quicker than the belief that someone else is getting something they're not.

Particularly when it's budgeted in the form of money, rather than services. No one's going to be envious of their mate having to go for tests all the time or spend a fortnight in hospital. But they'll be at their mate "being given more money than them."